DEMENTIA SERVICES REVIEW. Health and Social Care Needs Analysis. and analysis of Service Data

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1 DEMENTIA SERVICES REVIEW Health and Social Care Needs Analysis and analysis of Service Data April 2017 DOCUMENT TRAIL AND VERSION CONTROL SHEET Heading Dementia Health Needs Analysis and Service Data analysis Project Sponsor Kath Florey-Saunders To inform the Dementia Services Review Purpose of document giving an analysis of dementia health and social care needs and specialist service data Date of document April 2017 Review Date Authors Alex Geen, Suzie Green, Di Bardsley To be Approved by Dementia Services Review Project Board Date approved April 2017 Effective from April 2017 Status Final of version 2.6 Version 2.6 Supporting people in Dorset to lead healthier lives 1

2 Table of contents 1. Background The Policy Context Demography of Dorset Prevalence of dementia The Index of Multiple Deprivation Dementia diagnosis Wider Health Outcomes Health related quality of life for older people Recorded diabetes NHS Outcomes Framework Dementia co-morbidities Early-onset dementia Dementia mortality rates Dorset services data Memory Support and Advisory Service provided by Alzheimer s Society Memory Assessment Service, Dorset Health Care NHS Foundation Trust Community Mental Health Teams for Older People Dorset HealthCare NHS Foundation Trust Psychiatric Liaison Services - Dorset HealthCare NHS Foundation Trust Intermediate Care Service for Dementia (ICSD) Dorset HealthCare NHS Foundation Trust In Reach Services Dorset HealthCare NHS Foundation Trust Primary Care Prescribing Older Peoples Inpatient Services Acute Hospitals Local authority dementia services Delayed transfers of care Section 117 aftercare Workforce Summary

3 1. Background 1.1 NHS Dorset Clinical Commissioning Group (NHS Dorset CCG) and its local authority partners vision is for people with dementia and their family/carers to be enabled to live well with dementia, no matter what the stage of their illness or where they receive care. 1.2 The term dementia is used to describe a syndrome which may be caused by a number of illnesses in which there is progressive decline in many areas of function, including decline in memory, reasoning, communication skills and the ability to carry out daily activities. Alongside this decline, individuals may develop behavioural and psychological symptoms such as depression, psychosis, aggression and other challenging behaviours. The majority of people who are diagnosed with dementia have either Alzheimer s disease (62%) or vascular dementia (17%), or a combination of the two. Most types of dementia cannot be cured, but detecting it early can aid obtaining the right treatment and support and can help slow progression. 1.3 Nationally it is recognised that the mental health needs of the ageing population are set to increase. It is estimated that around 850,000 people across the UK have dementia. It is further estimated that about 6 per cent of the population over 65 have dementia and that after the age of 65, the prevalence of dementia doubles every five years so that about 30 per cent of those aged over 95 years are affected. Dementia can start before the age of 65, often presenting different issues for the person affected, affecting their career and family. It is estimated that early onset accounts for 2.2% of all people with dementia in the UK. 1.4 Figures from the Dementia 2012 report estimate that dementia costs 24 billion a year including NHS costs, social care costs, accommodation costs and informal care costs. This is a 41% increase from the 17 billion estimated in Across Dorset there are 187,456 people aged over 65, from this figure it is estimated that NHS Dorset CCG has 13,089 people aged over 65 living with dementia and across all ages it is estimated there is a total of 13, The priority for many people with dementia is to stay independent and live at home for as long as they can. However there are times when remaining at home is not safe and reduces quality of life. When this happens it is important that people living with dementia have access to a range of good quality provision that provides a nursing and / or residential home which can address their needs and is in a locality of their choice, wherever possible. 1.7 People with dementia represent a larger proportion of those in a long term care setting. Current estimates suggest just a third of people with dementia live in a care home and that of care home residents 69% have some form of dementia. Pan-Dorset, there were an estimated 4,088 people living with dementia in a care home in 2015; this is expected to increase to 6,210 by With complexity of cases requiring placement many people are remaining in their homes for longer and receiving increased care packages as their needs increase. When they do eventually need residential care their needs are at a level where they require nursing care and/or placements that can cater for complex needs hence there has been increase in recent years for nursing care placements and/or high cost placements, especially for conditions like dementia. 3

4 1.9 The pan Dorset residential and nursing care market across the three authorities is a mixed picture of provision and has some geographical inequality of provision with regard to the amount of beds needed in any one area to meet the needs of individuals with dementia especially around challenging behaviours and nursing care There is a lack of clarity in regard to care homes that are able to meet the needs of individuals with dementia as there is now no longer a regulatory standard for dementia from the Care Quality Commission. Furthermore the Care Quality Commission (CQC) has implemented a new inspection regime which in some cases has had a significant effect on smaller care homes Workforce is key to meet the demand for services and it is important that staff are appropriately skilled and confident in delivering care, support and treatment for people with dementia. Alongside ensuring appropriate dementia competencies are embedded within the workforce a more challenging and crucial part is recruitment from a declining working age population. This is a problem that is faced particularly in the South West and innovative solutions need to be collectively found The lack of workforce within the home care market has a negative impact particularly for people with dementia whom could be supported in their own homes through home care. Whilst every effort is made to enable an individual to remain in their own environment with the significant lack of workforce this is becoming more challenging to achieve In terms of dementia health based provision of services across Dorset, there are various dementia specialist services offering both community based assessment, diagnosis, support, care and treatment and specialist in-patient provision. However it is recognised that currently there is inequity of commissioned provision across East and West of the county. It is also noted that Dorset needs to review the current availability of post diagnostic treatment and support to consider how to ensure individual, family and carer needs are met Similarly to Social Care the shortage of NHS registered nursing staff providing dementia support, care and treatment has impacted on service provision and led to decisions around temporary closures of two inpatient settings at Betty Highwood, Blandford and Chalbury Unit, Weymouth. However, Alderney Hospital in Poole is open and has 41 commissioned beds available for dementia patients. 2. The Policy Context 2.1 The government focus on dementia began in 2009 with the Department of Health s five year strategy: Living well with dementia: a national dementia strategy for England and continued in 2012 with the launch of the three year challenge on dementia. The latest Prime Ministers Challenge on Dementia 2020 is a five year vision aimed at positioning England as the best country in the world for dementia care and research by The 2020 challenge recognises the growing body of evidence on the profound impact dementia is having on society. While it celebrates the significant progress made to date it also acknowledges that much more still needs to be done. 4

5 2.3 Goals within this challenge are measurable improvement on all areas of the Prime Minister s challenge on dementia 2020, including: maintain a diagnosis rate of at least two thirds; increase the numbers of people receiving a dementia diagnosis within six weeks of a GP referral; improve quality of post-diagnosis treatment and support for people with dementia and their carers. 3. Demography of Dorset 3.1 Dorset is a county in South West England comprising of the non-metropolitan county governed by Dorset and the unitary authority areas of Poole and Bournemouth (Diagram 1). 3.2 Dorset covers an area of 1,024 square miles and is bordered by Devon to the west, Somerset to the south west, Wiltshire to the north-east and Hampshire to the east. 3.3 The county town is Dorchester which is in the south-west of Dorset. The largest urban areas are Poole, Bournemouth, Christchurch and Weymouth & Portland. Around half the population lives in the south east area, while the rest of the county is largely rural with a low population density. Diagram 1. The county of Dorset 3.4 The main risk factor for dementia is increasing age; therefore it is important to understand how the population will age over time. The Projecting Older People Population Information System (POPPI) is provided by the Institute of Public Care for commissioners and others to understand and forecast future demand for services for the over-65 age group. This is currently forecasted from 2012 Office of National Statistics population statistics. Table 1 shows the total population and populations of those age 65 and 85 and over for Dorset, Bournemouth and Poole respectively, projected to Figures are taken from Office for National Statistics (ONS) subnational population projections by persons, males and females, by single year of age. The latest subnational population projections available for England, published 29 May 2014, are full 2012-based and project forward the population from 2012 to

6 Dorset: Total population 418, , , ,000 Dorset: Population aged 65 and over (% of total population) Dorset: Population aged 85 and over (% of total population) Bournemouth: Total population Bournemouth: Population aged 65 and over (% of total population) Bournemouth: Population aged 85 and over (% of total population) 117,300 (28.06%) 17,800 (4.26%) 127,500 (29.87%) 20,500 (4.80%) 139,400 (31.86%) 24,100 (5.51%) 154,300 (34.52%) 29,700 (6.64%) 192, , , ,700 34,900 (18.16%) 6,400 (3.33%) 37,400 (18.69%) 6,800 (3.40%) 41,100 (19.80%) 7,600 (3.66%) 46,400 (21.51%) 9,000 (4.17%) Poole: Total population 152, , , ,300 Poole: Population aged 65 and over (% of total population) 33,500 (22.02%) 36,500 (23.07%) 40,200 (24.51%) 45,000 (26.58%) Poole: Population aged 85 and over (% of total population) 5,500 (3.62%) 6,300 (3.98%) 7,300 (4.45%) 8,800 (5.20%) Dorset, Bournemouth and 762, , , ,000 Poole total population Dorset, Bournemouth and Poole population aged ,700 (24.36) 201,400 (25.65) 220,700 (27.28) 245,700 (29.53) and over (% of total population) Dorset, Bournemouth and Poole population aged 85 and over (% of total population) 29,700 (3.90) 33,600 (4.28) 39,000 (4.82) 47,500 (5.71) Table 1. Dorset, Poole and Bournemouth population aged over 65 and over 85 projected to Long-term subnational population projections are an indication of the future trends in population by age and sex over the next 25 years. They are trend-based projections, which means assumptions for future levels of births, deaths and migration are based on observed levels mainly over the previous five years. They show what the population will be if recent trends continue. The projections do not take into account any policy changes that have not yet occurred, nor those that have not yet had an impact on observed trends. 6

7 Number of people 3.5 The proportion of over 65s is forecast to increase as a percentage of the total population in Dorset, Bournemouth and Poole from 24% in 2015 to 30% in 2030 (Table 1). This is also presented in Chart 1 below. 180, , , , ,000 80,000 60,000 40,000 20, Chart 1. Estimate of Dorset population growth of over 65s to 2030 Dorset Bournemout h Poole 3.6 There are more females than males aged 65 and over in Dorset, Bournemouth and Poole. There is a large proportion of older people particularly in Dorset (28% over 65s in 2015) and Poole (22%). Bournemouth has a relatively younger age profile (18% over 65s in 2015) with an increased proportion of people around the age of 20. By comparison, over 65s comprised 17.7% of the UK population in Those born during the post-second world war baby boomer period from 1946 to 1964 are now in the age groups spanning 53 to 71 years of age. This cohort is likely to place increasing pressure on health services over the next 30 years due to the size of this population and the increase in life expectancy compared with previous cohorts. 3.8 Table 2 shows that the percentage of the over 65s black and minority ethnic (BME) population is 0.7% of the total pan-dorset population, with the highest population (1.3%) in Bournemouth and the lowest (0.4%) in Dorset, based on the ONS census By comparison, black and minority ethnic groups make up just under 20% of the all-age population of England and Wales, and 8% of the over 60s population viewoftheukpopulation/february ONS Census 2011, accessed via Nomis (Office for National Statistics ethnic classification: BME is defined by ONS as all groups except White British). Figures may not sum due to rounding. Figures are taken from the Census 2011, published by Office for National Statistics (ONS) on 16 May 2013, reference DC2101EW. Covering England and Wales, this dataset classifies the usual resident population of England and Wales as at census day, 27 March 2011 by ethnic group, by sex and by age. Ethnic group classifies people according to their own perceived ethnic group and cultural background. Numbers in this table have not been projected forward as the figures would not be reliable. 4 ONS Census 2011, accessed via Nomis (Office for National Statistics ethnic classification: BME is defined by ONS as all groups except White British) 7

8 3.9 Dorset has a young ethnic minority population; around 5% of those from ethnic minority groups are aged 65 years and over, whereas the Dorset population average (all ethnicities) of those aged 65 years and over is almost 25% 5. White Mixed/ multiple ethnic group Asian/ Asian British Black/ African/ Caribbean/ Black British Other ethnic group Total BME % BME of total population Bournemouth: Total population aged 65 and over 31, Dorset: Total population aged 65 and over 103, Poole: Total population aged 65 and over 29, Total 165, , Table 2. Ethnicity of over 65 Dorset, Poole and Bournemouth populations, 2011 (number of people) NHS Dorset Clinical Commissioning Group operates on the basis of a locality model with the geography of Dorset divided into 13 GP localities (Diagram 2). All 94 GP practices are sub-grouped into these locality groups (or geographical areas). Each locality has a Locality Chairperson (a local GP), who is also a member of the Governing Body which ensures CCG decisions are clinically-led Dorset is also served by three local authorities comprising the Borough of Poole (all age population estimate in 2017 of 153,220, 19.7% of pan-dorset population) 6, Bournemouth Borough Council (199,795, 25.7%) and Dorset County Council (423,289, 54.6%). 5 Dorset County Council. Available online: Accessed based Sub-National Population Projections, ; ONS, 8

9 Diagram 2. NHS Dorset Clinical Commissioning Group localities The Rural-Urban Classification of Local Authority Districts in England 7 categorises a range of statistical and administrative units on the basis of physical settlement and related characteristics taking into account the scale of their 'rural' and 'rural-related' population components, and their context - whether they lie within conurbations. The urban domain comprises all physical settlements with a population of 10,000 or more Dorset has an estimated total registered GP practice population of 793,496 split across urban and rural settings 8. The split between the two very different types of urban and rural geographies may impact on how services need to be modelled to deliver appropriate care in these environments. Table 3 shows the age profile of Dorset localities according to their Rural-Urban Classification Rural-Urban Classification of Local Authority Districts in England: User Guide (2014), Dept for Environment, Food and Rural Affairs and ONS. df 8 Registered Dorset GP practice population at

10 Age Band Locality Total Mainly Rural locality population as % of pan- Dorset population Over 65 population as % of pan- Dorset over 65 population Over 65 population as % of locality population North Dorset 64,054 22,727 86, Mid Dorset 32,608 11,492 44, Dorset West 28,132 12,973 41, Purbeck 24,109 9,957 34, Total Mainly Rural 148,903 57, , Urban with significant rural East Dorset 48,697 21,116 69, Urban with city and town Bournemouth North 55,516 11,292 66, Central Bournemouth 53,799 10,182 63, Christchurch 37,756 16,810 54, East Bournemouth 55,300 12,484 67, Poole Bay 57,402 16,760 74, Poole Central 49,334 13,248 62, Poole North 40,561 12,008 52, Weymouth & Portland 56,946 18,233 75, Total Urban with city and town 406, , , Grand Total 604, , , Table 3. Rural-Urban classification of NHS Dorset CCG localities by age 3.14 North Dorset has the highest number (22,727) of over 65s of all localities. Dorset West has the highest percentage of over 65s (32%) compared to the Dorset West locality population all-ages total, but with a relatively average over 65s population of 12,973. All mainly rural localities, and the urban with rural locality of East Dorset, have an equal or higher percentage of over 65 s compared with mainly urban localities. Central Bournemouth and Purbeck have the lowest percentage of over 65 s compared with the over 65 population pan-dorset. However, the Urban with City and Town localities combined have the highest number of over 65s pan-dorset These figures are based on GP practice registers and therefore do not account for the whole population of Dorset. Students, people who are homeless and insecurely housed, Roma, gypsy and travelling populations and ethnic migrants and refugees are less likely to be represented on GP practice registers than the general population. The actual population is likely to be larger, and the proportion of over 65 s is likely to be lower due to younger average ages of the non-gp registered population. 10

11 4. Prevalence of dementia 4.1 In 2014, Alzheimer s Society commissioned an international review of the evidence on the prevalence and costs of Dementia (Dementia UK update, 2014) 9. A methodology called the Expert Delphi Consensus was used which included a review of all available evidence by 13 senior academics. 4.2 The review found that the dementia population prevalence estimate for those aged 65 and over nationally was 7.1%. Two major population studies in the UK found different dementia prevalence rates: the MRC Cognitive Function and Ageing Studies I (7.5% prevalence) and II (6.4% prevalence). Table 4 shows prevalence estimates (%) of dementia by age based on the Expert Delphi Consensus. Prevalence increases with age from 0.9% of year olds to 41.1% of those aged 95+. There are many more females than males with dementia from the age of 85+; this could be explained by a combination of females being at an increased risk of developing some types of dementia and the higher proportion of females compared to males living longer (as previously shown in charts 2,3 and 4). Table 4. Comparison of current consensus estimates for the national prevalence (%) of late-onset dementia with estimate from previous literature reviews and key surveys. 4.3 Table 5 shows prevalence estimates (%) of dementia by age based on the Cognitive Functioning and Ageing Studies I and II. The overall prevalence for CFAS I was 7.5% (carried out across ), compared with 6.4% in CFAS II ( ). The reduction in prevalence suggests that later born populations have a lower risk of dementia than those born earlier in the past century. 9 Alzheimer s Society, Dementia UK update, Nov Available online: [Accessed ] 11

12 Table 5. CFAS I and II dementia prevalence Factors Impacting on Prevalence Rates / Risk Factors Care setting: 4.4 The Dementia UK update (2014) 10 also estimated the national prevalence of dementia in care settings, including extra care housing, residential homes, nursing homes and elderly mentally impaired care homes. Extra care housing is housing designed with the needs of frailer older people in mind and with varying levels of care and support available on site. People who live in Extra Care Housing have their own self-contained homes, their own front doors and a legal right to occupy the property. Extra Care Housing is also known as very sheltered housing, assisted living, or simply as 'housing with care'. It comes in many built forms, including blocks of flats, bungalow estates and 10 Dementia UK Update (2014). Kings College London and the London School of Economics, Alzheimer s Society. Available online Accessed

13 retirement villages. It is a popular choice among older people because it can sometimes provide an alternative to a care home. 4.5 The prevalence of dementia among residents of care homes is considered to be slightly higher in women than men at all ages, and to increase in age up to age 90, falling slightly among the oldest old. This could be as a result of women living longer than men. The total prevalence of dementia in care settings is estimated at 69.0% (62.7% for males and 71.2% for females). Care setting Female Male Total Extra care housing * Residential homes Nursing homes Elderly Mentally Impaired care homes *Consensus not achieved therefore this estimate should be treated with caution. Table 6. Estimates of the prevalence (%) of dementia in different care settings. 4.6 Dorset had an estimated 4088 people living with dementia in care homes in 2015; this is expected to rise by 52% to 6210 people by 2030; based on ONS population statistics and the Dementia UK 2014 findings that 69% of people living in care homes have dementia (see section 24 for a more detailed breakdown). Age: 4.7 Among people with late-onset dementia nationally (age 65+), most (54%) have mild dementia, followed by 32.1% with moderate dementia and 12.5% with severe dementia 11. The most prevalent type of dementia is Alzheimer s disease (62%), followed by vascular dementia (17%), mixed dementia (10%), dementia with Lewy bodies (4%), frontotemporal dementia (2%), Parkinson s dementia (2%) and other types (3%) Chart 2 below shows the prevalence of recorded dementia according to GP practice registers in England 12. This supports the research in the Dementia UK (2014) update, showing that prevalence increases with age and females are more likely to develop dementia than males. 11 Dementia UK Update (2014). Kings College London and the London School of Economics, Alzheimer s Society. Available online Accessed NHS Digital, available at Accessed

14 Chart 2. Observed prevalence of recorded dementia in England by age group and gender, England, December Table 7 shows the estimated population dementia prevalence by age and gender for Poole, Bournemouth and Dorset projected to This is based on the POPPI population statistics aged 65 and over by gender and the Dementia UK (2014) prevalence report (table 4). Between 2015 and 2030 the over-65 dementia prevalence is estimated to increase by 50% pan-dorset, with increases for every age group and gender. The greatest increase is in Poole males (63.4%), followed by Dorset males (62.3%); Bournemouth males (55.9%); Dorset females (47.9%); Poole females (43.3%) and Bournemouth females (32.2%). The dementia prevalence increases are directly linked to expected increases in the population size. The number of people with dementia aged 90+ is expected to increase the most for both genders between 2015 and 2030; however males aged 90+ will increase much more than females aged 90+; which could be a reflection of the gap in life expectancy reducing between genders. In 2015, the highest numbers of females with dementia were in the 90+ age group; however most males with dementia were in the age group. The 90+ age group is expected to have the highest number of people with dementia of both genders in 2030 in Dorset, Bournemouth and Poole with the exception of Dorset males, where the highest number of males with dementia is expected to be in the age group. 14

15 Estimated dementia prevalence (no. of people) Overall change % Population aged 65 and over by age and gender, projected to Poole: Males aged Poole: Males aged Poole: Males aged Poole: Males aged Poole: Males aged Poole: Males aged 90 and over Poole: Total males 65 and over Poole: Females aged Poole: Females aged Poole: Females aged Poole: Females aged Poole: Females aged Poole: Females aged 90 and over Poole: Total females 65 and over Bournemouth: Males aged Bournemouth: Males aged Bournemouth: Males aged Bournemouth: Males aged Bournemouth: Males aged Bournemouth: Males aged Bournemouth: Total males Bournemouth: Females aged Bournemouth: Females aged Bournemouth: Females aged Bournemouth: Females aged Bournemouth: Females aged Bournemouth: Females aged Bournemouth: Total females Table produced on 01/03/17 10:46 from version 9.0. Figures may not sum due to rounding. Crown copyright Figures are taken from Office for National Statistics (ONS) subnational population projections by persons, males and females, by single year of age. The latest subnational population projections available for England, published 29 May 2014, are full 2012-based and project forward the population from 2012 to Long-term subnational population projections are an indication of the future trends in population by age and sex over the next 25 years. They are trend-based projections, which means assumptions for future levels of births, deaths and migration are based on observed levels mainly over the previous five years. They show what the population will be if recent trends continue. The projections do not take into account any policy changes that have not yet occurred, nor those that have not yet had an impact on observed trends. 15

16 Population aged 65 and over by age and gender, projected to Estimated dementia prevalence (no. of people) Overall change % Dorset: Males aged Dorset: Males aged Dorset: Males aged Dorset: Males aged Dorset: Males aged 90 and over Dorset: Total males 65 and over Dorset: Females aged Dorset: Females aged Dorset: Females aged Dorset: Females aged Dorset: Females aged Dorset: Females aged Dorset: Total females Total Dorset, Bournemouth & Poole Table 7. Estimated dementia population aged 65 and over by age and gender, projected to Based on Dementia UK 2014 prevalence estimates by age and gender Table 8 shows the estimated population dementia prevalence by age and gender for Poole, Bournemouth and Dorset projected to This is based on the POPPI population statistics aged 65 and over by gender and the CFAS II prevalence report (table 5). CFAS dementia prevalence estimates are lower than the Dementia UK 2014 report estimates; however the overall prevalence estimate is similar (49.7%) and the pattern by age, gender and geography is similar. One area of difference is the greatest number of males with dementia in 2030 will be in the age group rather than the 90+ age group as estimated in the Dementia UK 2014 report. 14 Table produced on 01/03/17 10:46 from version 9.0. Figures may not sum due to rounding. Crown copyright Figures are taken from Office for National Statistics (ONS) subnational population projections by persons, males and females, by single year of age. The latest subnational population projections available for England, published 29 May 2014, are full 2012-based and project forward the population from 2012 to Long-term subnational population projections are an indication of the future trends in population by age and sex over the next 25 years. They are trend-based projections, which means assumptions for future levels of births, deaths and migration are based on observed levels mainly over the previous five years. They show what the population will be if recent trends continue. The projections do not take into account any policy changes that have not yet occurred, nor those that have not yet had an impact on observed trends. 16

17 Population aged 65 and over by age and gender, projected to 2030 Estimated dementia prevalence (no. of people) Overall change % Poole: Males aged Poole: Males aged Poole: Males aged Poole: Males aged Poole: Males aged Poole: Males aged 90 and over Poole: Total males 65 and over Poole: Females aged Poole: Females aged Poole: Females aged Poole: Females aged Poole: Females aged Poole: Females aged 90 and over Poole: Total females 65 and over Bournemouth: Males aged Bournemouth: Males aged Bournemouth: Males aged Bournemouth: Males aged Bournemouth: Males aged Bournemouth: Males aged Bournemouth: Total males Bournemouth: Females aged Bournemouth: Females aged Bournemouth: Females aged Bournemouth: Females aged Bournemouth: Females aged Bournemouth: Females aged Bournemouth: Total females Dorset: Males aged Dorset: Males aged Dorset: Males aged Dorset: Males aged Dorset: Males aged Dorset: Males aged 90 and over Dorset: Total males 65 and over

18 Population aged 65 and over by age and gender, projected to 2030 Estimated dementia prevalence (no. of people) Overall change % Dorset: Females aged Dorset: Females aged Dorset: Females aged Dorset: Females aged Dorset: Total females Total Dorset, Bournemouth & Poole Table 8. Estimated dementia population aged 65 and over by age and gender, projected to Based on CFAS II prevalence estimates by age and gender A dementia diagnosis significantly reduces a person s life expectancy. People with dementia, men and women, live an average of five years after diagnosis, though this can vary widely depending on the individual case. The overall trend indicates that living with dementia shortens a person s life, so that even if dementia is not the direct cause of death, there is a negative impact on the length and quality of someone s life After the age of 65, the risk of developing Alzheimer s disease doubles approximately every five years. According to population data, 72.5% of people aged 90 or over in the UK in 2012 were women. Today, an 85 year old woman is estimated to have an average 6.8 years of further life remaining. The unfortunate result of these trends is that many women are living their extra years in ill health 16. Ethnicity: 4.13 The Dementia UK Update (2014) 17 found that studies into the dementia prevalence of black, Asian and minority ethnic groups have been small in size and have not found any significant difference compared with the general population dementia prevalence. However the research does show a trend towards a higher prevalence of dementia amongst black, Asian and minority ethnic communities due to increased prevalence of risk factors including hypertension, diabetes, stroke and heart disease Majority1.pdf 16 Majority1.pdf 17 Dementia UK Update (2014). Kings College London and the London School of Economics, Alzheimer s Society. Available online Accessed

19 4.14 Public Health England (2015) carried out a systematic literature review to identify the prevalence of dementia in population groups by protected characteristics 18. Dementia was more common in people from African-American, black-caribbean or Hispanic background. There was no information published on people from south-east Asian backgrounds. The age of onset was lower for Black African-Caribbean groups than the white UK population. The increase in dementia amongst African- American and Hispanic populations compared with Caucasians appears to be correlated with increased prevalence of stroke and diabetes in these groups. Information from the 2011 Census indicates that there are substantial increases in the number of people from black and minority ethnic communities likely to be living with dementia, but the understanding of dementia in such communities is limited and the illness highly stigmatised Research by Age UK and the Race Equality Foundation 19 found that there was evidence to suggest that African-Caribbean and South Asian UK populations were more at risk of developing dementia than the general population. African-Caribbean populations may be more likely to have early-onset dementia due to the increased risk factors present for vascular dementia, such as hypertension. Most Black Minority Ethnic (BME) families migrating to the UK were of working age and were less likely to have older relatives around them, and so may not be familiar with dementia; this combined with a cultural expectation that older people are looked after within families, the stigma around mental health and a lack of awareness of services means that BME families are less likely to seek support and more likely to struggle with caring for older relatives with dementia. The use of community dementia navigators combined with Race Equality and Cultural Competency training for health and social care professionals could reduce late diagnoses of dementia and improve support for BME people through their treatment Pan-Dorset only 0.7% of the population are from a black or minority ethnic background, with the highest proportion (1.3%) in Bournemouth (table 2). Asian / Asian British people make up the highest proportion of the BME population pan-dorset, followed by Mixed Multiple Ethnic populations. Further investigation is needed to identify smaller geographical areas pan-dorset with higher proportions of BME populations to enable services to target these populations in a culturally appropriate way. 18 Public Health England (2015). Prevalence of dementia in population groups by protected characteristics. Available online: ure_review_matrix_report_-_final_for_web_-_ pdf Accessed Clayton, K., Butt, J., Islam-Barrett, F. & Gardner, Z. (2014) Dementia in black and minority ethnic communities: Meeting the challenge. (2014). Age UK and the Race Equality Foundation. Available online port%20-%20final%201_0.pdf Accessed

20 Gender: 4.17 Gender has long been widely reported as associated with the prevalence of dementia. Of the 850,000 people with dementia in the UK, 500,000 are women. It is estimated that 61% of people with dementia are women and 39% are men. This is likely to reflect the fact that women live longer than men and age is the biggest known risk factor for the condition - nearly three in four people over the age of 90 are women. Dementia is the leading cause of death for women and the third leading cause of death for men 20. Several studies have found that women are at increased risk for developing Alzheimer s Disease whereas men are more at risk of developing vascular dementia 21. Gender differences can be partly explained by hormonal differences, as women receiving hormone replacement therapy appear to show a reduced risk of developing Alzheimer s Disease; and higher rates of smoking, hypertension and poor vascular health in men are associated with higher rates of vascular dementia Dorset had the highest estimated number of males with dementia in 2015 (2812); greater than Poole and Bournemouth combined (1670) (table 8). Females had the same pattern, with 5098 in Dorset and 3236 in Poole and Bournemouth combined. Co-morbidities / Long Term Conditions: 4.19 Diabetes doubles an individuals risk of dementia and stroke appears to be a strong risk factor for vascular dementia especially when due to hypertension. Hypertension is the most important remediable risk factor for stroke and vascular dementia. There is substantial evidence to suggest that elevated blood pressure earlier in life is a risk factor for vascular dementia in later life 22. Dorset and Poole have a similar recorded diabetes prevalence to the England average (6.4%) and Bournemouth is lower than the England average at 5.2% Depression is associated with increased risk of dementia however the reasons for this association are unclear 23 and it is not known whether depression increases the risk of dementia or whether it is an early sign of dementia Majority-Infographic.pdf 21 McCullagh, C.D., Craig,D., McIlroy, S.P. & Passmore, A.P. (2001) Risk factors for dementia. British Journal of Psychology. Available online Accessed Lindsay, J., Hebert, R. & Rockwood, K. (1997) The Canadian Study of Health and Aging Risk Factors for Vascular Dementia. Available online secsha Accessed Public Health England (2015). Prevalence of dementia in population groups by protected characteristics. Available online: ure_review_matrix_report_-_final_for_web_-_ pdf Accessed McCullagh, C.D., Craig,D., McIlroy, S.P. & Passmore, A.P. (2001) Risk factors for dementia. British Journal of Psychology. Available online Accessed

21 4.21 Parkinson's disease is a fairly common neurological disorder in older adults, estimated to affect nearly 2% of over 65 years. It is estimated that 50 80% of those with Parkinson's disease eventually experience dementia: dementia with Lewy bodies or Parkinson s disease dementia. The difference between them lies mainly in how the disease starts. In dementia with Lewy bodies, the person may have a memory disorder but later develop movement and other distinctive problems, such as hallucinations. In Parkinson s disease dementia, the person may initially have a movement disorder that looks like Parkinson's but later also develop dementia symptoms Adults with developmental disabilities have increased incidence of depression and dementia. All individuals with Down s syndrome have the characteristic neuropathology of Alzheimer's disease by the age of 40, and although not all will develop dementia, it is extremely common A systematic review of the prevalence of dementia in population groups by protected characteristics 25 recommended that Public Health England consider conducting modelling studies to begin to estimate the impact on increasing prevalence of dementia caused by known differential rates of depression, diabetes and cardiovascular disease between groups. Education: 4.24 Increased early life education is strongly associated with reduced risk of dementia according to the findings of three large longitudinal studies of ageing 26. The studies assessed participants for up to 20 years and are three of only six such studies in the world, and found that people with different levels of education have similar brain pathology but that those with more education are better able to compensate for the effects of dementia Chart 7 shows the education, skills and training domain of the Indices of Deprivation for Dorset localities. 5. The Index of Multiple Deprivation 5.1 The Index of Multiple Deprivation (IMD) is an overall relative measure of deprivation constructed by combining seven domains of deprivation according to their respective weights. LSOAs (Lower-layer Super Output Areas) are small geographical areas designed to be of a similar population size, with an average of approximately 1,500 residents or 650 households. There are 32,844 Lower-layer Super Output Areas (LSOAs) in England. They were produced by the Office for National Statistics for the reporting of small area statistics. The seven domains in the IMD are: 25 (2015) ure_review_matrix_report_-_final_for_web_-_ pdf 26 University of Cambridge (2010). Why more education lowers dementia risk. Available online: Accessed The EClipSE collaboration, which combines the three European population-based longitudinal studies of ageing (the Medical Research Council Cognitive Function and Ageing Study, the Cambridge City Over-75s Cohort Study and Vantaa 85+, a Finnish study). 21

22 Rank (1-326) Income Deprivation (22.5%) Employment Deprivation (22.5%) Education, Skills and Training Deprivation (13.5%) Health Deprivation and Disability (13.5%) Crime (9.3%) Barriers to Housing and Services (9.3%) Living Environment Deprivation (9.3%) 5.2 The two domains of Education, Skills and Training Deprivation; and Health Deprivation and Disability are separately presented in this report. As described in section 4, poor vascular health is a risk factor for dementia and educational attainment is a protective factor in reducing the impact of dementia and so these domains may act as proxy measures for dementia prevalence. Index of Multiple Deprivation - overall Locality Chart 3. English Indices of Deprivation 2015, by lower layer super-output area, ranked (1 = most deprived in England, 326 = least deprived in England). 5.3 Of pan-dorset localities, Weymouth and Portland is the most deprived (rank 103), followed by Bournemouth (rank 117). West Dorset (207), Poole (208), North Dorset (210) and Purbeck (211) are similar, with Christchurch (259) and East Dorset (303) being the least deprived the latter being in the least deprived decile in England (Chart 3). 22

23 Rank (1-326) 5.4 The Education, Skills and Training Domain measures the lack of attainment and skills in the local population. The indicators fall into two sub-domains: one relating to children and young people and one relating to adult skills. These two sub-domains are designed to reflect the flow and stock of educational disadvantage within an area respectively. That is, the children and young people subdomain measures the attainment of qualifications and associated measures ( flow ), while the skills sub-domain measures the lack of qualifications in the resident working-age adult population ( stock ). The following measures are included in the children and young people sub-domain: Key Stage 2 attainment: The average points score of pupils taking reading, writing and mathematics Key Stage 2 exams; Key Stage 4 attainment: The average capped points score of pupils taking Key Stage 4; Secondary school absence: The proportion of authorised and unauthorised absences from secondary school; Staying on in education post 16: The proportion of young people not staying on in school or nonadvanced education above age 16; Entry to higher education: A measure of young people aged under-21 not entering higher education. The Adult Skills sub-domain is a non-overlapping count of two indicators: Adult skills: The proportion of working age adults with no or low qualifications, women aged 25 to 59 and men aged 25 to 64. English language proficiency: The proportion of working age adults who cannot speak English or cannot speak English well, women aged 25 to 59 and men aged 25 to 64. Locality Chart 4. Education, Skills and Training Domain, ranked by lower layer super output area. Rank 1 = least educational attainment in England; 326 = most educational attainment. 23

24 Rank (1-326) 5.5 Of pan-dorset localities, Purbeck has the least educational attainment (rank 105) followed by Weymouth and Portland (rank 113). East Dorset has the most educational attainment (rank 229) followed by Christchurch (rank 217) and West Dorset (rank 206) (Chart 4). 5.6 The Health Deprivation and Disability Domain measures the risk of premature death and the impairment of quality of life through poor physical or mental health. The domain measures morbidity, disability and premature mortality but not aspects of behaviour or environment that may be predictive of future health deprivation. The measures included are: Years of potential life lost: an age and sex standardised measure of premature death; Comparative illness and disability ratio: an age and sex standardised morbidity/disability ratio; Acute morbidity: an age and sex standardised rate of emergency admission to hospital; Mood and anxiety disorders: a composite based on the rate of adults suffering from mood and anxiety disorders, hospital episodes data, suicide mortality data and health benefits data. Locality Chart 5. Health Deprivation and Disability domain, ranked by lower layer super output area. Rank 1 = most deprived in England; 326 = least deprived. 5.7 The population of East Dorset has the least health deprivation and disability of all pan-dorset localities (rank 308), falling only just outside of the best 5% of localities in England, followed by Christchurch and North Dorset (rank 264 and 262 respectively), West Dorset and Purbeck (rank 228 and 224 respectively), Poole (rank 163), Bournemouth (rank 126) and the most deprived Weymouth and Portland (rank 56, bottom 20% in England) (chart 5). 24

25 5.8 There may be an increase in dementia prevalence in areas with greater deprivation due to the links between dementia and vascular health, diabetes and education. Weymouth and Portland, Bournemouth and Purbeck rank in the worst of pan-dorset localities for overall deprivation, education skills and training and health deprivation and disability. Purbeck has a small over 65 population and so the impact of deprivation will be less than in Weymouth & Portland and Bournemouth where there are larger over 65 populations. Poor vascular health, diabetes and education are modifiable risk factors. There may be a benefit to including services that support and promote health such as public health and the NHS in dementia pathways especially in the areas with greater deprivation. 6. Dementia diagnosis 6.1 A timely dementia diagnosis enables people living with dementia, and their carers/families to access treatment, care and support, and to plan in advance in order to cope with the impact of the disease. It also enables primary and secondary health and care services to anticipate needs, and working together with people living with dementia, plan and deliver personalised care plans and integrated services, thereby improving outcomes. 6.2 NHS England requires specific recorded Dementia diagnoses data to support the National Dementia Strategy and the Prime Minister s Challenge on Dementia An ambition to increase the rate of dementia diagnosis has been agreed by NHS England and is specified in the NHS Mandate 27. The overall 2020 goals include maintaining a diagnosis rate of at least two thirds of prevalence rate; to increase the numbers of people receiving a dementia diagnosis within six weeks of a GP referral and to improve quality of post-diagnosis treatment and support for people with dementia and their carers. 6.3 NHS England has adopted the prevalence estimate of the MRC Cognitive Function and Ageing Studies II (CFAS II) of 6.4% of over 65s 28. Table 8 (page 18) estimates the change in the number of people with dementia in Bournemouth, Dorset and Poole between 2015 and 2030 based on ONS population statistics and the prevalence estimates of CFAS II. To achieve the ambition of two-thirds diagnosis rate by 2020, table 9 shows the dementia prevalence and numbers needed for two-thirds prevalence in Dept of Health (2013). The Mandate. A mandate from the Government to the NHS Commissioning Board: April 2013 to March Available online accessed Alzheimer s Society, Dementia UK update, Nov Available online: [Accessed ] 25

26 Area 2020 dementia prevalence (based on CFAS II) Poole males Poole females Bournemouth males Bournemouth females Dorset males Dorset females Total two-thirds of dementia prevalence Table 9. Estimated prevalence of dementia in Dorset in 2020 based on POPPI population statistics and CFAS prevalence data. 6.4 To help monitor this ambition, NHS Digital collect data on a monthly basis from general practice systems to produce an aggregated number of people at each general practice with a diagnosis of dementia, as well as the general practice s total registered population. These data are published on their website These data are collected as part of the Quality and Outcomes Framework (QOF). The objective of the QOF is to improve the quality of care patients are given by rewarding practices for the quality of care they provide to their patients. QOF is therefore an incentive payment scheme, not a performance management tool, and a key principle is that QOF indicators should be based on the best available research evidence. The QOF only reflects part of the work that a general practice is responsible for; it measures only those conditions specified by NICE in the GMS contract. As such it is not recommended to use the QOF data to rank practices into league tables. Furthermore, a practice which has no patients who have a particular QOF-measured condition, cannot score any QOF points for that clinical area, and could wrongly be perceived as being a lower performer in any rank of points scored. This is particularly pertinent for specialist centres and those with specific demographics, e.g. a university practice whose patients are primarily students The aggregated data required are based on Practice List Size Attribute and Dementia Indicator DEM002 of the Dementia Ruleset elements of the Quality Outcomes Framework (QOF) business rules v32.0 published by NHS Digital 31. The following items are included in this data collection: 29 Health and Social Care Information Centre (2015). Collection of aggregated numbers of patients in England with a record of dementia diagnosis on their clinical record. Available online Accessed NHS Digital, (2015) Quality and Outcomes Framework Available online Accessed HSCIC QOF Business Rules Dementia Indicator Set (2015). Available online: Accessed

27 Number of patients who have a diagnosis of dementia for each general practice in England at the end of each calendar month for the financial year The codes used to define dementia are those used in the QOF business rules v32.0. The data to be collected in gender categories: Male, Female, and Unknown/Not Specified. The data to be collected in age categories: 0-29; 30-34; 35-39; 40-44; 45-49; 50-54; 55-59; 60-64; 65-69; 70-74; 75-79; 80-84; 85-89; and 90+. The total number of patients registered with the general practice. Using these data recorded prevalence for each practice can be calculated as follows: Recorded dementia prevalence = (Number of patients on dementia register / Number of patients registered at practice) x Tables 10 and 11 show the number of people diagnosed with dementia on GP practice registers by locality at March 2016 and January 2017, for 0-64 years and 65+ years respectively. The numbers of under-65s diagnosed is small and therefore it is not possible to identify any trends (table 9). The proportion of dementia diagnoses for ages 65+ in January 2017 was 79.8% in Poole, 77.6% in Bournemouth, and 57.7% in Dorset (table 10). This is based on an estimated dementia population prevalence of 6.4% (of over 65s) and the number of those age 65+ on GP practice registers. Dorset diagnosed the same percentage in March 2016 and January 2017; although 86 more people were on the dementia register in January 2017 (the GP registered population had also increased). Poole exceeded the diagnosis rate in January 2017 by 13.1% but the register had reduced by 1.3% or 37 fewer on the register compared with March Bournemouth has reduced by 1.9% and had 40 fewer people on the dementia register in Jan 2017; however is 11% above the target diagnosis rate of 66.7%. In January 2017 Dorset was below the target by 9%; 696 extra people on the dementia register would be needed to meet the target (table 10). 6.8 The total dementia diagnosis rate in March 2016 was 66.8% and in January 2017 was 65.6%; based on GP practice registers and not on the ONS population statistic that is currently used by NHS England to calculate achievement against the target. 27

28 Aged 0-64 Years March 2016 January 2017 Locality Dementia Register % Prevalence Dementia Register % Prevalence Christchurch % % East Dorset % % Mid Dorset % % North Dorset % % Poole Bay % % Bournemouth North % % Central Bournemouth % % Dorset West % % Poole Central % % Poole North % % Purbeck % % Weymouth & Portland % % East Bournemouth % % Total % % Table 10. Recorded diagnoses of early-onset dementia on GP practice registers by locality, age

29 Aged 65 Years & Over 2015/16 As at Jan 2017 Locality Dementia Register % Prevalence % of estimated dementia population diagnosed Dementia Register % Prevalence % of estimated dementia population diagnosed Variance to target Dorset West % 48.4% % 39.1% 291 North Dorset % 54.7% % 56.3% 149 Mid Dorset % 56.3% % 59.4% 57 Purbeck % 60.9% % 59.4% 50 Christchurch % 60.9% % 62.5% 50 East Dorset % 57.8% % 62.5% 63 Weymouth & Portland % 64.1% % 64.1% 36 Dorset Total % 57.7% % 57.7% 696 Bournemouth North Central Bournemouth East Bournemouth Bournemouth Total % 59.4% % 62.5% % 82.8% % 76.6% -57* % 95.3% % 87.5% -170* % 79.5% % 77.6% -196* Poole North % 71.9% % 70.3% -24 Poole Central % 75.0% % 82.8% -126* Poole Bay % 92.2% % 84.4% -186* Poole Total % 81.1% % 79.8% -336* Total 65+ Registered Population 185, ,531 Total varian ce 164 Table 11. Recorded diagnoses of late-onset dementia on GP practice registers by locality, age 65+. *negative numbers indicate that the target has been exceeded. 6.8 Charts 6-8 (and table 11) show the dementia register variation in localities in January All three Poole localities are above the target rate of 66.7% (chart 6). The Bournemouth area overall is above the target rate; however North Bournemouth is below the target rate by 4.2% or 31 people (chart 7). All Dorset localities are below the target rate; the worst performing being Dorset West (27.6% below target) and the best performing is Weymouth and Portland (2.6% below target) (chart 8). 29

30 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% % of estimated dementia population diagnosed - Poole 70.3% 82.8% 84.4% Target (66.7%) % of estimated dementia population diagnosed 20.0% 10.0% 0.0% Poole North Poole Central Poole Bay Chart 6. % of estimated population diagnosed in Poole localities, January % 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% % of estimated dementia population diagnosed - Bournemouth 62.5% Bournemouth North 76.6% Central Bournemouth 87.5% East Bournemouth Target (66.7%) % of estimated dementia population diagnosed Chart 7. % of estimated population diagnosed in Bournemouth localities, January

31 70.0% 60.0% % of estimated dementia population diagnosed - Dorset 56.3% 59.4% 59.4% 62.5% 62.5% 64.1% Target (66.7%) 50.0% 40.0% 39.1% 30.0% 20.0% 10.0% % of estimated dementia population diagnosed 0.0% Chart 8. % of estimated population diagnosed in Dorset localities, January

32 7. Wider Health Outcomes Public Health Outcomes Framework 7.1 The Public Health Outcomes Framework Healthy lives, healthy people: Improving outcomes and supporting transparency 32 sets out a vision for public health, desired outcomes and the indicators that demonstrate how well public health is being improved and protected. The framework concentrates on two high-level outcomes to be achieved across the public health system, and groups further indicators into four domains that cover the full spectrum of public health. The outcomes reflect a focus not only on how long people live, but on how well they live at all stages of life. 7.2 The data published in the tool are the baselines for the Public Health Outcomes Framework, with more recent and historical trend data where these are available. The baseline period is 2010 or equivalent, unless these data are unavailable or not deemed to be of sufficient quality. Life expectancy 7.3 Life Expectancy at Birth is the age a person would expect to live based on contemporary mortality rates. 7.4 Dorset females are expected to live to an average of 85 years which is better than the England and South West region averages of 83.2 and 83.9 respectively. The same measure for males is 81.5, also better than the respective England and South West region averages of 80.2 and 81.3 (Chart 9) 33. Above average life expectancies partly explain the higher number of older people living in Dorset compared with the England average. 7.5 Bournemouth females are expected to live to an average of 83.1 years which is similar to the England and South West region averages of 83.2 and 83.9 respectively. The same measure for males is 78.9, which is worse than the respective England and South West region averages of 80.2 and 81.3 (Chart 9). 7.6 Poole females are expected to live to an average of 84.1 years which is better than the England average of 83.2 and similar to the South West region average of The same measure for males is 80.6, also better than the England average of 80.2 and similar to the South West region average of 81.3 (Chart 9). Healthy Life Expectancy at Birth 7.7 This is the average number of years a person would expect to live in good health based on contemporary mortality rates and prevalence of self-reported good health framework#page/3/gid/ /pat/6/par/e /ati/102/are/e /iid/91872/age/1/sex/4/nn/nn-1- E

33 7.8 The male population of Dorset has a Healthy Life Expectancy at Birth of 67 years, better than the England average of 63.3 and South West region average of The same measure for females is 65.2 years which is worse than the male average and similar to the England and South West region averages of 63.9 and 65.5 respectively (Chart 9). 7.9 The male population of Bournemouth has a Healthy Life Expectancy at Birth of 63.6 years, similar to the England average of 63.3 and worse than the South West region average of The same measure for females is 63.9 years which is similar to the male average and the England and South West region averages of 63.9 and 65.5 respectively (Chart 9) The male population of Poole has a Healthy Life Expectancy at Birth of 65.5 years, better than the England average of 63.3 and similar to the South West region average of The same measure for females is 66.6 years which is better than the male average and better than the England and South West region averages of 63.9 and 65.5 respectively (Chart 9) Of the 15 areas within the South West region 34, Dorset is one of six areas (the others are Bristol, North Somerset, South Gloucestershire, Swindon and Wiltshire) with a higher Healthy Life Expectancy for males compared with females. Life expectancy at This is the age a person would be expected to live based on contemporary mortality rates Male life expectancy at 65 years is 20.2 years in Dorset, better than the England and South West region averages of 18.8 and 19.3 respectively. Female life expectancy at 65 years is 22.7, also better than the England and South West region averages of 21.2 and 21.8 respectively (Chart 9) Male life expectancy at 65 years is 18.8 years in Bournemouth, similar to the England and South West region averages of 18.8 and 19.3 respectively. Female life expectancy at 65 years is 21, also similar to the England and South West region averages of 21.2 and 21.8 (Chart 9) Male life expectancy at 65 years is 19.4 years in Poole, better than the England average of 18.8 and similar to the South West region average of Female life expectancy at 65 years is 21.7, better than the England average of 21.2 and similar to the South West region average of 21.8 (Chart 9) In summary, females have a longer life expectancy than males across Dorset, Bournemouth and Poole, including the measures at birth and at 65 years. However, healthy life expectancy for females compared with males is worse in Dorset, similar in Bournemouth and better in Poole. 34 Not including Isles of Scilly due to a lack of data. 33

34 Chart 9. Healthy life expectancy at birth; life expectancy at birth; and at 65 (male /female), England and South West region comparisons with Dorset, 2012/ Health related quality of life for older people 8.1 Health status is derived from responses to Q34 on the GP Patient's Survey 35, which asks respondents to describe their health status using the five dimensions of the EuroQuol 5D (EQ-5D) survey instrument: Mobility Self-care

35 Usual activities Pain / discomfort Anxiety / depression 8.2 This indicator assesses whether health-related quality of life is changing over time, while controlling for potential measurable confounders (age, sex, long-term conditions, caring responsibility, etc.) 8.3 Bournemouth and Dorset both have a Health related quality of life score that is better than the England average and similar to the South West region average (Chart 10). Poole has a similar score to the England average, along with Bristol and Swindon. Plymouth is the only area in the South West to perform worse than the England average. Chart 10. Health related quality of life for older people 8.4 In summary, Dorset has a higher life expectancy at birth (LE) and at age 65 for males and females than the South West region and England averages (LE is 85 and 81.5 respectively). However, healthy life expectancy, which is the number of years a person would expect to live in good health based on contemporary mortality rates and prevalence of self-reported good health; is lower for females than males (65.2 and 67), and the female rate pan-dorset is equal to the South West and England averages whereas the pan-dorset male rate is higher. This may be a reflection of factors such as females living longer than males; the increased likelihood that females will be carers for other relatives or a partner; and the increased risk of developing Alzheimer s disease. 9. Recorded diabetes 9.1 The Recorded diabetes indicator is the prevalence of Quality and Outcomes Framework (QOF) recorded diabetes in the population registered with GP practices aged 17 and over (Chart 11). 9.2 Dorset and Poole (both 6.3%) are similar to the England average (6.4%) for recorded diabetes. Bournemouth is lower than the England average at 5.2%. Diabetes is a risk factor for developing dementia, and so it may be of benefit to combine diabetes and dementia pathways pan-dorset in order to provide a service which recognises early signs of dementia and to support people with dementia and diabetes to improve their health and reduce the severity of their diabetes. 35

36 Chart 11. % of QOF-recorded cases of diabetes registered with GP practices aged NHS Outcomes Framework 10.1 The NHS Outcomes Framework sets out the outcomes and corresponding indicators that will be used to hold the NHS to account for improvements in health outcomes, as part of the government s mandate to NHS England. The outcomes are measured as part of the Quality Outcomes Framework (QOF) through general practice Chart 12 shows GP recorded diagnoses of dementia risk factors including three indicators of poor vascular health: Coronary Heart Disease; Stroke or Transient Ischaemic Attack (TIA); and Hypertension; Depression; and Diabetes. It shows the recorded diagnoses on GP registers for Dorset CCG, Southampton CCG and West Hampshire CCG (blue dots, in that order), plus the England (vertical line) and Wessex cluster (pink square) averages. The latter two CCG s were chosen as high and low scoring comparators g CCGs respectively for dementia diagnosis across Wessex cluster. 36

37 Chart 12. Quality Outcomes Framework indicators for Coronary Heart Disease, Stroke or TIA, Hypertension, Depression and Diabetes, 2014/ The recorded diagnoses on GP registers of Coronary Heart Disease for Dorset CCG (4.13%) is higher than the England average of 3.25% and higher than that for West Hampshire and Southampton CCGs (3.33% and 2.49% respectively) and the cluster of 3.38% The recorded diagnoses for Stroke or TIA and Hypertension are also higher in Dorset (2.31% and 15.4% respectively) compared with West Hampshire and Southampton CCGs and higher than the England average (1.73% and 13.8%) and cluster average (1.9% and 14.3%) for both of these indicators Southampton CCG has the lowest recorded diagnoses for all three indicators which could be a reflection of a younger population profile Dorset, Southampton and West Hampshire CCGs all have similar recorded diagnoses of depression, similar to the England average and cluster average Dorset has a similar recorded rate of diabetes (6.03%) compared with the England average of 6.37% and cluster average (6.02%). Dorset is higher than both Southampton and West Hampshire which are both below the England average In summary, Dorset has higher recoded diagnoses of vascular risk factors for dementia, with a lower diagnosis of diabetes and similar diagnoses of mental health, compared with the England and cluster averages. This could be a reflection of the older age profile of the population of Dorset for the vascular risk factors, as they are more prevalent in older people. It is not known how complete and timely the data is, and one explanation for the difference could possibly be that Dorset is better at recording diagnoses of particular health conditions compared with other areas. Dementia services 37

38 may need to support people to improve their health to reduce the impact of co-morbidities such as these on dementia; and services for coronary heart disease, stroke, TIA, hypertension and diabetes may benefit from being able to identify early signs of dementia and having the skills to support people with a dual diagnosis including dementia. 11. Dementia co-morbidities 11.1 Physical co-morbidities are common in those with dementia and can lead to disability and lower quality of life for both patients and their carers. Many people with dementia have multiple comorbidities Analysis of the GP and prescribing records of the population of Richmond-upon-Thames showed that only 5% of those with dementia had no other chronic conditions recorded. In contrast, 15% had two or more and 71% had 3 or more, including depression, diabetes, heart disease and respiratory conditions (Yuen, P. and O Sullivan, C. 2013/14) A published article by Fox et al. (2014) gives a detailed summary of co-morbidities in people with dementia. An estimated 61% have 3 or more co-morbidities including diabetes, chronic obstructive pulmonary disorder, musculoskeletal disorders and chronic cardiac failure. Musculoskeletal, genitourinary, and ear, nose and throat disorders affect nearly 50%. Many of the co-morbidities are often treatable and some may be reversible. Epilepsy, delirium, falls, oral disease, malnutrition, frailty, incontinence, sleep disorders and visual dysfunction occur more frequently. If left untreated, they can lead to more severe health problems, pain and distress as well as worsening the symptoms of dementia itself. The rate of co-morbid conditions increases with dementia severity. Pneumonia, urinary tract infections and congestive cardiac failure accounted for two-thirds of preventable admissions in dementia, while dehydration and duodenal ulcer the next most important Healthcare costs for treating these problems are high, estimated as 34% more costly than in agematched, non-dementia cases. The annual admission rate is double that of patients without dementia. The promotion and maintenance of independence and everyday functioning is crucial and should include a comprehensive assessment of needs, difficulties and possible co-morbid symptoms Timely identification of physical symptoms in those with dementia is associated with decreased risk of hospitalisation, reduced healthcare costs and the maintenance of physical comfort and quality of life. The diagnosis and management of co-morbid conditions is often poor, and this can lead to increased morbidity and mortality. Co-morbidity and poor management can also give rise to an increased burden on the carer. 38

39 12. Early-onset dementia 12.1 Lambert et al. (2014) 36 reviewed the different challenges experienced by those with early onset dementia (usually arbitrarily set at up to 65 years of age) and their family and carers. Challenges are due to the stage of life that is interrupted and also the duration of disease and include difficulty in diagnosing dementia, the impact on family members and employment and the impact on household resources and support Carers of those with early onset appear to experience high levels of psychological suffering and specific problems related to their phase in life (Van Vliet D et al, 2010) 37. Problems include relational problems, family conflict, problems with employment, financial difficulties, and problems concerning diagnosis The quality of life for carers of people with early onset dementia improves with the increased age of carers and with patients' insight into their condition. Carers are more likely to experience depression if they are married, have offspring and are caring for a patient with dementia and a comorbid cardiovascular disease. A reduction in depression is seen in carers when patients received domiciliary nursing care Dementia mortality rates 13.1 In 2014, 1,524 people who died in Dorset (aged 20+ years) had a recorded mention of dementia 39. The directly age standardised rate of mortality for those with a recorded mention of dementia aged >=20 years is per 100,000. This is not significantly different from the England average of 188 per 100,000. The >=20 years population of Dorset was 633,582 (at ). Therefore an estimated 1144 people with dementia in Dorset died in 2015/16. If all of these people were on the dementia quality outcomes framework register then 1144 new diagnoses would be needed in 2015/16 just to maintain the register size The directly age standardised rate of mortality for those with a recorded mention of dementia aged >=65 years is 720 per 100,000. This is not significantly different from the England average of 750 per 100,000. The trend for both the above indicators for NHS Dorset has been increasing significantly over the past four years Deaths in usual place of residence: The percentage of deaths in usual place of residence for people with a recorded mention of dementia in Dorset was 70.8%. This is significantly higher than the England average of 67.5%. The trend has increased significantly over the past four years. 36 Lambert et al, Estimating the burden of early onset dementia; systematic review of disease prevalence 37 Vliet D et al, Impact of early onset dementia on caregivers: a review. Int J Geriatric Psychiatry 38 Rosness TA, Mjørud M, Engedal K, Quality of life and depression in carers of patients with early onset dementia. Int J Geriatric Psychiatry 39 Public Health England Dementia Profile. Available online Accessed

40 13.4 Deaths in usual place of residence, care homes: The percentage of deaths in usual place of residence for people with a recorded mention of dementia in Dorset was 61.6%. This is significantly higher than the England average of 51.5%. These proportions have remained stable over the past three years Deaths in usual place of residence, hospital: The percentage of deaths in usual place of residence for people with a recorded mention of dementia in Dorset was 28.7%. This is significantly lower than the England average of 31.4%. The trend has been decreasing over the past four years Deaths in usual place of residence, home: The percentage of deaths in usual place of residence for people with a recorded mention of dementia in Dorset was 8.7%. This is not significantly different from the England average of 8.4% 13.7 The overall Dorset mortality rate for people with a dementia diagnosis is similar to the England average. Most people die whilst living in care homes (61.6%), followed by hospital (28.7%) and at home (8.6%). Dorset has a higher proportion of people dying in care homes than the England average and a lower proportion of people dying in hospital. The mortality rate for people with a dementia diagnosis has significantly increased in the last four years. 40

41 14. Dorset services data 14.1 The dementia specialist services in table 12 are within the scope of the Dementia Services Review. Data from these various services is presented in the following section to help identify areas of need and gaps. The Memory Gateway Service comprising Memory Support and Advisory Service and Memory Assessment Services referral Pathway can be found in Appendix 1. Dorset Healthcare NHS Foundation Trust 48 commissioned In-patient beds Alderney Hospital 16 commissioned In-patient beds Chalbury Unit (currently closed) 12 commissioned In-patient beds Betty Highwood (currently closed) In-reach Service for care homes Psychiatric Liaison Services Intermediate Care Service for Dementia (ICSD) East and West providing an intensive support service Older persons Community Mental Health Teams Haymoor Day Hospital at Alderney Weymouth Melcombe Day Unit Memory Assessment Service Alzheimer s Society Borough of Poole Bournemouth Borough Council Memory Support and Advisory Service Care UK: Specialist dementia care at home (domiciliary) Specialist Care Home providers and Community Home Care contractors Early Help and Prevention services commissioned by BBC to support people living with dementia in the community Dorset County Council Various Dementia Care Home and Dementia Respite Care Commissioned Care homes providing dementia care Home Care providers Table 12. Services in scope of the dementia review. 41

42 15. Memory Support and Advisory Service provided by Alzheimer s Society 15.1 The Memory Support and Advisory Service (MSAS) works to provide expert practical guidance and support to people affected by memory problems and dementia. Memory Advisers support people worried about their memory through pre-diagnostic screening and through the diagnosis process if required and continue to offer support after diagnosis. This includes understanding of the condition, coping with the day-to-day challenges dementia brings and preparing for the future. The service also supports carers of people with dementia; providing information, advice and signposting The service operates across Dorset (including Bournemouth and Poole) from 9am to 5pm Monday to Friday. Referrals to this service are made by health professionals, carers and people concerned about their memory, by telephone or fax to a central contact number staffed by office based Memory Advisers Alzheimer s Society also runs 16 Memory Cafes, 9 Singing for the Brain groups, a Carers group, 2 informal coffee mornings and 4 Peer Support groups for young people with dementia Table 13 below shows the number of pre-diagnosis referrals to MSAS by locality in 2015/16, 2016/17 to December and forecast for 2016/17 and table 14 shows the number of pre- and post-diagnosis referrals. Locality 15/16 total 16/17 to Dec 16 total 16/17 Forecast Bournemouth North Central Bournemouth Christchurch Dorset West East Bournemouth East Dorset Mid Dorset North Dorset Poole Bay Poole Central Poole North Purbeck Weymouth & Portland Unknown Non Dorset <5 <5 5 NHS England 0 <5 <5 Total Table 13. Referrals to MSAS - pre-diagnosis 42

43 Locality 2014/ / /17 Forecast Central Bournemouth East Bournemouth Bournemouth North Christchurch Dorset West East Dorset Mid Dorset North Dorset Poole Bay Poole Central Poole North Purbeck Weymouth & Portland Unknown Non Dorset Grand Total Table 14. Referrals to MSAS pre- and post-diagnosis MSAS Referrals - Pre & Post Diagnosis / / /17 FoT (Feb 17) Chart 13. MSAS pre- and post-diagnosis referrals by GP locality and year ( forecast from year to February dataset). 43

44 15.5 The MSAS service was commissioned by NHS Dorset CCG, Borough of Poole, Bournemouth Borough Council and Dorset County Council and launched in September Table 13 shows that prediagnosis referrals to the MSAS service for 2016/17 are forecast to be greater than in 2015/16 in every locality which reflects the development, marketing and awareness of this new service. Table 14 shows a more mixed picture of pre- and post-diagnosis referrals with variation between localities and years and no clear trend. Many pre- and post-diagnostic referrals were not allocated by locality (Table 14) which reduces the quality of the data. Chart 13 shows that most pre- and post-diagnosis referrals in 2015/16 were for people registered with a GP in East Dorset, followed by Christchurch and Weymouth & Portland; in 2016/17 Bournemouth North, East Dorset, and Weymouth and Portland are expected to be in the top three localities for referrals. Mid-Dorset, East Bournemouth and Central Bournemouth had the lowest number of referrals of Dorset localities across both years North Dorset and East Dorset have the highest populations of over 65s, followed by Weymouth and Portland, Christchurch and Poole Bay. Weymouth and Portland has high levels of deprivation which may contribute to the prevalence of vascular dementia due to the link between deprivation and poor health. Charts 14 and 15 show the rate of pre-diagnosis referrals to the MSAS service per 1000 over 65 population. In both years shown, Weymouth and Portland and North Dorset have below average rates of referrals to the MSAS whereas it would be expected that these localities would have higher than average referral rates due to the high number of over 65s and in the case of Weymouth & Portland, high deprivation. Christchurch has above average referral rates probably due to the high population of over 65s; the population in this locality has a high level of education which may also explain the higher rate of referrals. MSAS Referrals - rate per 1, Pop 2015/ CCG Average Chart 14. MSAS pre-diagnosis referrals rate per population 2015/16 44

45 MSAS Referrals - rate per 1, Pop /17 YTD Nov 16 CCG Average Chart 15. MSAS pre-diagnosis referrals rate per population 2016/17 to Nov Memory Assessment Service, Dorset Health Care NHS Foundation Trust 16.1 The Memory Assessment Service (MAS) provides assessment, diagnosis and where possible treatment of dementia. The service is provided by Dorset HealthCare and was set up in 2012 for individuals aged over eighteen registered with a Dorset GP who are experiencing a memory problem. The service operates Monday Friday, 9.00am 5.00pm and is based at locations across the county including Bournemouth and Poole, offering appointments at a number of community hospitals, in some GP surgeries and in patients own homes In 2014 the service formed a partnership working arrangement with the Memory Support and Advisory Service provided by the Alzheimer s Society and operating as a primary care service. Together the two services formed the Memory Gateway (see appendix). This helped to raise the profile of services available locally for people living with memory loss, and led to a significant increase in the number of people being referred to the service. It also meant that the different memory services in Dorset could work more closely together in supporting people diagnosed with dementia Referral to the Memory Assessment Service is via the Memory Gateway. All patients referred are seen by the Memory Support and Advisory Service first, who undertake some memory screening to determine if seeing the Memory Assessment Service would be helpful. The first appointment with the Memory Assessment Service is with a nurse, who gathers information from the person and their family / those they are close to, as well as undertaking a number of memory exercises or tests. Following this, the Memory Assessment Nurse discusses the results with the team doctor and considers whether it would be helpful to arrange a brain scan to help confirm the diagnosis. An appointment is then arranged with the Memory Assessment Service Doctor to explain the diagnosis. 45

46 16.4 There are a number of different types of dementia and part of the diagnosis appointment will explain what type a person has. For some types of dementia, such as Alzheimer s Disease, a medication can be offered to help slow down memory loss. If a medication is started, a memory nurse will monitor this for the first year before the person is discharged back to their GP for further medication monitoring. The Memory Support and Advisory Service provide ongoing support after diagnosis for people with dementia and their carers For other types of dementia such as vascular dementia, medication won t be helpful. Therefore the Memory Assessment Service transfers the person s care back to the Memory Support and Advisory Service for ongoing support. If the person with dementia has more complex needs and requires more intensive support, they would be referred on from the Memory Assessment Service to the Older Person s Community Mental Health Team. Table 15 and Chart 16 show the number of referrals to the MAS service based on the locality of the patient s GP for 2014/15, 2015/16, 2016/17 to Dec and a forecast for the year. 2016/17 YTD Dec 2016/17 Forecast 3 year total Locality 2014/ /16 Bournemouth North Central Bournemouth Christchurch Dorset West East Bournemouth East Dorset Mid Dorset North Dorset Poole Bay Poole Central Poole North Purbeck Weymouth & Portland Grand Total 2,140 2,129 1,599 2,132 6,401 Table 15. Number of referrals to MAS service by locality and year 46

47 MAS Referrals by Locality 2014/ / /17 FoT (M9 Dec 16) Chart 16. Number of referrals to MAS service by locality and year 16.6 Weymouth and Portland locality had the most referrals to the MAS across the three years, followed by North Dorset, East Dorset and Poole Bay. These localities also have the highest populations of over 65 year olds in Dorset. However deprivation may be an influencing factor. For example North Dorset has 22,014 over 65 year olds and Weymouth and Portland has 17,463, and so deprivation could explain why a higher proportion of referrals are from Weymouth and Portland. Furthermore, a proportion of under 65s are diagnosed which could account for variation when comparing with population statistics of over 65s. The lowest number of referrals was from Central Bournemouth, North Bournemouth and East Bournemouth. Central Bournemouth has the lowest populations of over 65s in Dorset which could explain the low referral numbers Chart 17 and Table 16 show the number of diagnoses made by the MAS service by locality and year and highlight the difference across the urban and rural split. 47

48 No. of MAS Diagnoses Year Urban/Rural locality ccg 2014/ / /17 YTD Dec /17 FoT Rural Dorset West Mid Dorset North Dorset Purbeck Rural Total Urban Bournemouth North Central Bournemouth Christchurch East Bournemouth East Dorset Poole Bay Poole Central Poole North Weymouth & Portland < Urban Total Unknown/Non Dorset Grand Total 1,206 1,018 1,034 1,631 Table 16. MAS service diagnoses by locality and year 48

49 Dorset West Mid Dorset North Dorset Purbeck Bournemouth North Central Bournemouth Christchurch East Bournemouth East Dorset Poole Bay Poole Central Poole North Weymouth & Portland MAS No. of Diagnoses by Year / / /17 Rural Urban Chart 17. MAS diagnosis number by urban / rural split and year 16.8 Of rural localities, Dorset West had the highest number of diagnoses across the three years (284) and East Bournemouth was the highest of the urban localities with 303 referrals. Christchurch and Mid Dorset also had high numbers of diagnoses. The localities with the lowest number of diagnoses were Weymouth & Portland, Purbeck, Bournemouth North and Poole Central. This is in contrast to the population figures for older people in Dorset localities, which would suggest that North Dorset, East Dorset and Weymouth & Portland would have the highest dementia diagnoses due to the highest populations of over 65s, and are amongst the highest localities for numbers of referrals to the MSAS and MAS services. This is a particularly stark contrast with the low number of diagnoses in Weymouth and Portland An estimated 1144 people with dementia in Dorset died in 2015/16 (see point 13.1). If all of these people were on the dementia quality outcomes framework register then 1144 new diagnoses would be needed in 2015/16 just to maintain the register size. There were 1018 diagnoses in 2015/16, 126 less than the estimated number of deaths, which would result in a reduction of the register size. In 2016/17 the forecast for diagnoses is 1,631 which may lead to an increase in the register size although this will be tempered by an increased population size and therefore increased number of dementia deaths Table 17 shows the MAS diagnosis rate per 1,000 population over-65 which supports chart 17 in showing a low rate of diagnoses for Weymouth & Portland, East Dorset and North Dorset. 49

50 Rate per 1,000 Locality population Purbeck 15 North Dorset 9 Mid Dorset 23 Dorset West 22 Weymouth & Portland 6 Bournemouth North 13 Poole Central 12 East Dorset 9 Central Bournemouth 19 Poole Bay 14 Poole North 21 Christchurch 16 East Bournemouth 24 Total 20 Table 17. MAS diagnosis rate per 1,000 population (65+) based on 2014/15, 2015/16 and 2016/17 forecast (based on year to Dec 2016) Table 18 shows diagnosis type by locality for 2014/15 and 2015/16 combined. Most diagnoses were for Alzheimer s Disease (884), followed by mixed dementia (381) and vascular dementia (319). Christchurch and Dorset West had the highest number of diagnoses of Alzheimer s and Mixed Dementia. Weymouth and Portland had a relatively low number of diagnoses of any type considering the large over-65 population and high level of deprivation. Locality Alzheimers Mixed Dementia Vascular Dementia Other Total Bournemouth North Central Bournemouth Christchurch Dorset West East Bournemouth East Dorset Mid Dorset North Dorset Poole Bay Poole Central Poole North Purbeck Weymouth & Portland 13 7 < No locality recorded Grand Total ,224 Table 18. MAS diagnoses by dementia type and locality (2014/15 and 2015/16 combined) 50

51 16.12 The other diagnosis group includes the following: Delirium Mental and behavioural disorders Mild cognitive disorder Dementia in Parkinsons / Huntingtons / Picks Disease The following case study gives an example of the support that can be offered by the Memory Gateway: Miss A is 83 years old and lives alone in her own home in Bournemouth. She has an older sister who lives in the local area who she sees regularly and a niece and nephew who visit several times a year. She attends church twice a week and sometimes goes along to social events organised by the church. She drives and owns a car and tends to get out every day to walk her dog. Miss A has been quite independent up until the last year when she started to become more muddled and forgetful. She would sometimes get confused about dates and times she had agreed to meet her sister and was not managing to get her weekly food shop done very well anymore which meant she wasn t eating quite so well. Sometimes she would do things like make tea for her sister and use out of date milk, which was very unlike her. She would also forget whether she had sorted out things like the electricity bill, which caused her a lot of worry. Miss A was encouraged by her sister to visit her GP about her memory and they attended an appointment together. Her GP ran some blood tests and discussed making a referral to the Memory Gateway for Miss A, which she agreed to. Two weeks later she was visited at home by a Memory Advisor from the Memory Support and Advisory Service. She spent some time talking to them about what had been happening and the impact this had on her. The Memory Advisor felt that based on the information gathered and the results of the memory screening exercise she had completed, that it would be helpful to see the Memory Assessment Service, so she made an onward referral. Four weeks later Miss A attended an appointment at community hospital with her sister to see the Memory Assessment Nurse. The nurse went back through the information gathered so far and checked that any actions agreed with the Memory Advisor were being progressed. She then asked Miss A to undertake some memory assessment tools to see how she got on. Miss A did find this quite difficult and the nurse spent time reassuring her that they weren t a test and couldn t be failed, they were designed to help understand what was happening with her memory. During the appointment, the nurse discussed that a brain scan would be the best thing to understand what was happening with her memory. Miss A agreed to attend the local hospital for a scan and received an appointment for 4 weeks later. Miss A then attended an appointment with the Memory Assessment Service doctor, who explained that the results showed she had the early stages of an Alzheimer s dementia. The doctor started a medication to help slow down the process of memory loss, which the memory nurse then monitored for the first year. After a year, Miss A was discharged back to her GP. She will sees the Memory Advisor occasionally if she needs support and can call them at any time if things change. She continues to be supported by her sister and has recently had involvement from social services to arrange a care worker to visit daily to help her with her medication and check she has had something to eat. She is also now considering going along to her local day centre. 51

52 17. Community Mental Health Teams for Older People Dorset HealthCare NHS Foundation Trust 17.1 The Older Persons Community Mental Health Teams (OPCMHT) provide a service to individuals registered with a Dorset GP who have a severe and enduring mental health condition including dementia. Teams are based at various community locations through the county, including Bournemouth and Poole and operate Monday Friday, 09.00am 5.00pm The OPCMHTs are comprised of doctors (including consultant psychiatrists), community mental health nurses, support time recovery workers, occupational therapists and administration staff. There is also access to psychology. In Bournemouth and Poole, the teams also have Social Workers within the team, whereas in Dorset, the Social Workers do not work directly in the OPCMHT but work from a local social services department The OPCMHTs help people who have conditions such as schizophrenia, bipolar disorder, depression, anxiety and personality disorders (this list is not exhaustive). As well as offering support to people over 65 with these mental health conditions (known as functional mental illness ), the OPCMHTs also support people with an organic mental illness such as dementia. The team does not support every person living with dementia, as many people are well supported by their GP, the Memory Support and Advisory Service, the Memory Assessment Service, as well as family, friends, and home care agencies or care home providers. The OPCMHTs particular role is to support clients who have behavioural and psychological symptoms in dementia, which means they have challenging behaviours that pose risks to themselves or potentially others, such as wandering, disinhibition or aggression. The team develop a care plan with the person and their carers, taking into account the persons wishes where known, to help the person live as well as possible with their dementia, and to plan for the future The OPCMHTs mostly receive referrals from GPs, however they do accept referrals from other health and social care professionals and non-statutory agencies as well as self-referrals. A Care Coordinator or Lead Professional is assigned to patients under the care of the team who provide regular support and reviews Mental health problems increase with age, for example, dementia affects over 5% of those aged over 65 years and 20% over 80 years. Moderate to severe depression occurs in 3-4% of the older adult population. The highest prevalence of depression is found in those aged over 75 years. There are significant co-morbidities with a range of other health conditions such as Parkinson s disease, stroke and neurological conditions, which all increase the risk of depression. Twenty percent of people over 65 develop psychotic symptoms by age 85, and most are not a precursor to dementia A limitation to the OPCMHT service data is that dementia is not recorded as a diagnosis and therefore it is not possible to know how many service users have dementia. Table 19 shows the number of referrals to the Community Mental Health Teams for Older People based on the locality of the service users GP and covers the years 2014/15, 2015/16 and 2016/17. The same data is presented in Chart Joint Commissioning Panel for Mental Health, (2013). Guidance for Commissioners of Older People s mental health services. Available online at Accessed

53 17.7 A Crisis Response and Home Treatment Team is available as part of the OPCMHTs, however this does not support people with dementia, and therefore this is currently a service gap. There is an out of hours emergency social care team that supports people with dementia which is included in the local authority section (point 24.10). Year Locality 2014/ / /17 3 year total North Dorset ,656 Weymouth & Portland ,330 East Dorset ,114 Mid Dorset Poole Bay East Bournemouth Christchurch Dorset West Central Bournemouth Purbeck Poole Central North Bournemouth Poole North Unknown Grand Total 3,639 3,460 3,575 10,674 Table 19. Referrals to Older People s Community Mental Health Team by locality and year 53

54 CMHT Older People Referrals by Year 2014/ / /17 Chart 18. CMHT Older People Referrals by locality 14/15, 15/16 and 16/ The highest numbers of referrals across the three years were for people registered with GP practices in North Dorset (1656), followed by Weymouth and Portland (1330) and East Dorset (1114). The lowest numbers were for Poole North (420), North Bournemouth (489) and Poole Central (554). This correlates with the distribution of older people in Dorset, with the highest number of older people living in North Dorset (22,014) followed by East Dorset (21,273) and Weymouth and Portland (17,463) The following case study gives an example of the support that can be offered by the Older Person s Community Mental Health Team: Mr B has been married for 38 years and lives with his wife in Poole. He has always been a strong character who was very organised and liked his routine. He had been an army officer and had enjoyed being a military man. He still had many friends locally who he had served in the army with and enjoyed meeting them at the pub regularly. Mr B and his wife had two sons, who had both also served in the army. Mr B had been diagnosed with a mixed dementia in the early stages back in 2014 which had been very difficult for him to accept. He had managed quite well for a couple of years with the support of his family and close friends and had been helped by keeping to his weekly routine. However in the last six months he had been finding daily tasks more and more difficult and was becoming very frustrated. Mr B had been going out as usual to walk to the local pub or shop and had been getting lost, sometimes for several hours, which had been extremely stressful for his wife. His sons had found him on the occasions he had wandered off and it had taken quite a long time to calm him down again. Most recently, he had become frustrated when he could not work out the television to watch a regular programme he liked and he threw the remote control at his wife, which was very out of character. He had also at times started to become quite verbally abusive and threatening towards his wife, who was struggling to help him around the house as much due to her own poor physical health. On one occasion he had also grabbed her by her arm and caused a bruise when he would not let go. 54

55 The family had been coping quite well in the past and had declined any offer of a care agency or meals on wheels but this was now putting too much pressure on Mrs B. Mr B had been referred to the Older Person s Community Mental Health Team when he had started to get lost as his GP was concerned about his dementia worsening and causing some challenging behaviours and that his wife was vulnerable. Mr B was seen five days later by the Consultant Psychiatrist and a Community Mental Health Nurse. The doctor started some medication for Mr B and the nurse was assigned as care coordinator to provide ongoing support and regular reviews. The nurse also arranged for a social worker to visit to assess for what other help could be provided in the home. They also looked at the safeguarding concerns about the risks to Mrs B and offered her a carers assessment and worked with the sons on a safety plan for Mr and Mrs B to help them remain in their own home. The OPCMHT will continue to see Mr and Mrs B regularly until the risks have reduced and they have the support in place that they need to enable them to continue living at home. 18. Psychiatric Liaison Services - Dorset HealthCare NHS Foundation Trust 18.1 Liaison psychiatry services address the mental health needs of people who find themselves in an acute hospital setting receiving treatment primarily for physical health problems or symptoms. The prevalence of mental illness among people with physical health conditions is two to three times higher than in the rest of the population. Around half of all inpatients suffer from a mental health condition such as depression, dementia or delirium, which can lead to poorer health outcomes, including increased rates of mortality and morbidity NHS Dorset CCG commissions a pan Dorset Psychiatric 24/7 Liaison Service operating from three acute hospital sites - Dorset County Hospital NHS Foundation Trust, Poole Hospital NHS Foundation Trust and Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust. The service ensures that older people also have access to timely psychiatric assessment and the team has the right skills mix to deliver appropriate care. The service in Dorset provides psychiatric assessment for patients in A&E departments and all other wards in Dorset when necessary. The service doesn t record a diagnosis of dementia and so it is not possible at this point to evidence the number of people with dementia accessing the service. 19. Intermediate Care Service for Dementia (ICSD) Dorset HealthCare NHS Foundation Trust 19.1 The Intermediate Care Service for Dementia (ICSD) was commissioned in April 2013 to provide a service in the East of Dorset from 7:30 to 19:30 Monday to Sunday, covering Poole, Bournemouth, Swanage, Christchurch, Wimborne and Ferndown/West Moors/Verwood. The Service provides an urgent care response to needs arising in the community including residential and nursing homes. The service assesses all referrals to determine the appropriate intervention to enable patients to receive care in their normal place of residence and will gate-keep access to mental health inpatient care across both East and West of the county overall. 41 Parsonage, M., Fossey, M. and Tutty, C. (2012) Liaison Psychiatry in the Modern NHS. Centre for Mental Health. Available online Accessed

56 19.2 The service offers time limited contact with patients for up to six weeks, with the aim of providing the service until such time as the situation has been sufficiently stabilised for ongoing care to be delivered at a lower level of intensity. The service also offers support to carers and ensures they are able to access a carer s assessment if required. Whilst formal commissioning of this service across the West of Dorset needs to be considered within the Dementia Review the service is beginning to be rolled out as pilots in some west localities based on the same principles and outcomes. Year Locality 2014/ / /17 FOT 3 year total NULL East Dorset Poole Bay Poole Central East Bournemouth Central Bournemouth North Bournemouth Christchurch Poole North Purbeck Mid Dorset < Weymouth & Portland Dorset West North Dorset <5 0 <5 5 Grand Total Table 22. ICSD referrals by locality and year 56

57 90 80 ICSD Referrals By Locality and Year 2014/ / /17 FOT Chart 20. ICSD referrals by locality and year 19.3 Table 22 and Chart 20 shows that the most referrals to the ICSD across the three years were from patients registered with GP practices in East Dorset (147), Poole Bay (139) and Poole Central (123). East Dorset has the highest population of older people of East localities, so a high level of referral to the ICSD from East Dorset is expected The area of Poole is ranked 56th for Health Deprivation and Disability, with 1 being the worst in England and 326 being the best; which suggests a high level of impaired quality of life in this area. There are high numbers of referrals to the ICSD from Poole Bay and Poole Central (the Indices of Deprivation do not drill down to this level). Conversely, Christchurch, with the third highest population of older people in East localities, has relatively few referrals to the ICSD, and the lowest Health Deprivation and Disability rank in Dorset (308). To note there previously has been a dementia service operating from Royal Bournemouth and Christchurch Hospitals operating from Christchurch (OPAL) Further investigation is required into whether there is a link between use of the ICSD and deprivation; bearing in mind that the service covers the East of the county where Poole and Bournemouth have higher levels of deprivation. Furthermore, the service is for all ages; although it is likely that the majority of service users will be over 65 based on dementia prevalence estimates. 57

58 Referral Source 2014/ / /17 FoT Internal - Community Mental Health Team (Older People) Year Internal Community Mental Health Team Internal - Inpatient Service (Older People) Other Table 23. ICSD referrals by referral source 19.6 Table 23 shows that the ICSD received most referrals from the Community Mental Health Team for Older People which would have been to support inpatient referral or admission. Referrals from inpatient services would have been to support inpatient discharge The following case study gives an example of the support that can be offered by the Intermediate Care Service for Dementia (ICSD). Mr C is an 82 year old gentleman who was diagnosed with Dementia in Alzheimer s in April Mr C is a retired groundsman who lives in his own home with his wife in Weymouth. Mrs C is Mr C s main carer. Mr and Mrs C have a daughter who lives locally (and visits approximately once a fortnight) and a son who lives in the north of the country who visits rarely. Mrs C is well supported by a Community Psychiatric Nurse (CPN), who visits regularly but has no other assistance with her husband s care needs. Late 2016 Mrs C reported to her CPN that Mr C was becoming increasingly aggressive during personal care and she was feeling less able to cope. Mrs C showed the CPN some bruising that had been caused by her husband. Respite care and hospital admission were discussed with Mrs C, however she was determined to have her husband stay at home with her. The CPN asked Mrs C if she would consider having the ICSD service in to help her, up to three times per day. Mrs C was reluctant but agreed to one visit per day. ICSD received the referral and visited Mr and Mrs C with the CPN. Initially 1 staff from ICSD visited every morning to help Mrs C with Mr C s personal care, after approximately 3 days Mrs C agreed for two members of staff to provide personal care while she took a break as she was exhausted. After approximately 3 further days Mrs C agreed for twice daily visits as she felt she could trust the staff. Mrs C expressed that she had been reluctant to accept help with Mr C s care as a previous care agency (some years ago) had been provided to help her, however, they never interacted with Mr C and she found this unacceptable. Mrs C was pleased that after providing personal care ICSD would spend time with Mr C helping to engage him in discussions around sports and his family. Mrs C reported that following these visits Mr C appeared happier and calmer for a short period of time (approximately 2-3 hours). A third visit per day was offered, however, Mrs C declined. After approximately 6 weeks staff in ICSD felt that, given the right education and support a care agency could be providing Mr C s personal care- as approach and interaction were the key to assisting Mr C. Mrs C reluctantly agreed and a care agency were commissioned. ICSD continued to support the agency on a reducing input basis:- Days 1-3 two staff from ICSD demonstrating techniques to agency staff and helping them engage with Mr C. 58

59 Days 4-10 one staff from ICSD to assist 1 member of agency staff in providing Mr C s personal care and engagement with Mr C Days agency staff to provide care with 1 member of ICSD to observe, intervene if necessary and provide support to Mrs C. Day 15- final ICSD visit with CPN to discharge Mr C back to the Community Mental Health Team. 20. In Reach Services Dorset HealthCare NHS Foundation Trust 20.1 The In-reach service is based in the East of Dorset but does reach further into other localities. The team consists of 3 Band 6 RMNs providing case management for those not on the caseload for CMHT; providing support and training to care homes and community hospitals for functional and organic illnesses Table 24 shows referrals to the in-reach service based on the locality of the patients GP. Most referrals across the three years were from Poole Central (129), followed by Poole North (100) and Purbeck (59). Areas with the least referrals were North Dorset (<5), Weymouth & Portland (17) and East Bournemouth (19) and this would be due to the fact the service is an East of Dorset service Table 25 shows that most referrals were for patients in the age groups followed by In 2014/15, the highest age group for referrals was 90-99, declining in 2015/16 and 2016/17. This could suggest that the average age of people in care homes and community hospitals is reducing; or that people are receiving earlier intervention; or that older people are more likely to have dementia and those people moved over to the ICSD; or the difference may be due to chance. 2016/17 to Dec /17 FoT 3 year total Locality 2014/ /16 Central Bournemouth Christchurch 20 6 <5 <5 29 East Bournemouth 7 < East Dorset 9 < North Bournemouth North Dorset < <5 Poole Bay <5 <5 47 Poole Central Poole North Purbeck Weymouth & Portland 5 < No locality recorded 0 <5 0 0 <5 Grand Total Table 24. Referrals to the in-reach service by locality and year 59

60 Age Band 2014/ / /17 to Dec /17 FoT 3 year total <5 <5 < <5 <5 16 Grand Total Table 25. Referrals to the in-reach service by age 2016/17 to Dec /17 FoT 3 year total Locality 2014/ /16 Central Bournemouth Christchurch East Bournemouth East Dorset North Bournemouth North Dorset < <5 Poole Bay < Poole Central Poole North Purbeck Weymouth & Portland No locality recorded <5 0 0 <5 Grand Total Table 26. Attendances or contacts with the in-reach service by locality and year 20.4 Table 26 shows that the most attendances/contacts with the in-reach service were in 2014/15 and have reduced each year since. Localities with the highest attendances/contacts across the three years were Poole Central (334), Poole North (267) and Purbeck (190) aligning to where the service was commissioned. The least activity was in North Dorset (<5), Weymouth & Portland (43) and East Bournemouth (60). 60

61 21. Primary Care Prescribing 21.1 All prescribing for dementia in primary care is done under a shared care arrangement between the GP and the specialist. Under shared care, it is usual for the diagnosis to be made and treatment started by a specialist, the GP can then take on prescribing responsibilities once the patient has been stabilised on the treatment for three months. A shared care guideline is available on the pan Dorset formulary to support this arrangement here NICE has produced guidance on supporting people with dementia (CG42) and the medicines available to treat dementia (TA217). The following information is taken from the shared care guideline: Donepezil is the first line choice, an alternative should only be considered if there is evidence of Lewy Body dementia or parkinsonian symptoms. However, an alternative acetylcholinesterase inhibitor (Galantamine or Rivastigmine) could be prescribed where it is considered appropriate having regard to adverse event profile, expectations about adherence, medical comorbidity, possibility of drug interactions, and dosing profiles. Memantine can be considered if the patient is intolerant of the initial AChE inhibitor or if the patient has developed severe Alzheimer s disease Table 27 and chart 21 shows the number of items (individual prescriptions) for each of the dementia drugs prescribed by each locality compared to the number of patients on the dementia register in 2015/16. If all patients with dementia are coded appropriately and on the dementia register, are prescribed a dementia treatment and all prescriptions are for 28 days the figure would be 12, a lower figure could be because: Not all patients on the dementia register are prescribed a treatment Prescriptions are for more than 28 days 21.4 Localities with a higher figure could be because: They prescribe more 28 day prescriptions More patients with dementia are prescribed a treatment Coding of patients with dementia is poor so the dementia register is not reflective of the population with a diagnosis of dementia. 61

62 Bournemouth Central Bournemouth East Bournemouth North Christchurch East Dorset Mid-Dorset Locality North Dorset Poole Bay Poole Central Poole North Purbeck West Dorset Weymouth and Portland Items per Pt on Dementia Register Locality Donepezil Rivastigmine Galantamine Memantine Bournemouth Central Bournemouth East Bournemouth North Christchurch East Dorset Mid-Dorset Locality North Dorset Poole Bay Poole Central Poole North Purbeck West Dorset Weymouth and Portland Table 27. Items per patient on the dementia register, 2015/16 Items per Pt on Dementia Register Memantine Rivastigmine Galantamine Donepezil Chart 21. Items per patient on the dementia register, 2015/16 62

63 21.5 Table 28 and chart 22 shows the items (individual prescriptions) for each drug as a percentage of the total prescribing for dementia medicines in each locality. Donepezil is first line as expected; it has the highest proportion of prescribing. Variation in this chart could be because: Elderly populations have more patients with severe Alzheimer s so an alternative to Donepezil is required Different specialists in secondary care or the memory service vary in their adherence to the formulary recommendations Variation in willingness to provide an adequate trial of first line drugs. % Items by Locality Locality Donepezil Rivastigmine Galantamine Memantine Bournemouth Central 68.93% 7.31% 5.93% 17.83% Bournemouth East 60.30% 8.63% 7.99% 23.08% Bournemouth North 72.00% 4.70% 5.27% 18.03% Christchurch 59.39% 11.60% 6.89% 22.12% East Dorset 54.16% 9.32% 17.42% 19.11% Mid-Dorset Locality 56.03% 12.41% 12.41% 19.15% North Dorset 62.42% 9.98% 6.18% 21.42% Poole Bay 59.85% 7.52% 8.23% 24.40% Poole Central 55.48% 11.26% 7.30% 25.96% Poole North 61.91% 6.50% 9.24% 22.36% Purbeck 75.14% 7.10% 9.97% 7.79% West Dorset 63.96% 12.13% 9.32% 14.58% Weymouth and Portland 72.10% 9.83% 9.43% 8.64% Table 28. % of items by locality, 2015/16 63

64 Bournemouth Central Bournemouth East Bournemouth North Christchurch East Dorset Mid-Dorset Locality North Dorset Poole Bay Poole Central Poole North Purbeck West Dorset Weymouth and Portland % Items by Locality 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Memantine Rivastigmine Galantamine Donepezil Chart 22. % of items by locality, 2015/ The price of each of the drugs varies widely, with all formulations of Galantamine and Rivastigmine patches being particularly more expensive than the other drugs. Donepezil is the cheapest of them all which is reflected in the fact it accounts for most of the items but not a large proportion of the cost (table 29 and chart 23). Variation is due to the number of items prescribed and the proportions of each drug prescribed; a locality with a high number of items per patient or a high proportion of Galantamine will appear higher on this chart. 64

65 Bournemouth Central Bournemouth East Bournemouth North Christchurch East Dorset Mid-Dorset Locality North Dorset Poole Bay Poole Central Poole North Purbeck West Dorset Weymouth and Portland Cost per Pt on Dementia Register ( ) Locality Donepezil Rivastigmine Galantamine Memantine Bournemouth Central Bournemouth East Bournemouth North Christchurch East Dorset Mid-Dorset Locality North Dorset Poole Bay Poole Central Poole North Purbeck West Dorset Weymouth and Portland Table 29. Cost per patient on dementia register, 2015/16 Cost per Pt on Dementia Register Memantine Rivastigmine Galantamine Donepezil Chart 23. Cost per patient on dementia register, 2015/16 65

66 22. Older Peoples Inpatient Services 22.1 A review of Older People Mental Health Services across the East of the country was taken forward during At this time there were 6 organic older people s wards across the county in three areas including long-term inpatient wards in the East of the County with Dorset noted to have much higher bed numbers than the national average. Following this review services were developed to provide care closer to home with the development of the Intermediate Care Service for Dementia (ICSD) in the East in April The Review also led to Alderney Hospital in Poole having a major refurbishment and a reconfiguration of beds with up to 48 commissioned beds for patients with organic illness on the East of Dorset. Inpatient provision was supported by a new service Intermediate Care Service for Dementia (ICSD) and a revised day hospital Dorset HealthCare NHS Foundation Trust currently provides the following inpatient services: Functional beds are provided in the East and West of the county. Alumhurst at St Ann s Hospital, Poole provides 20 beds and Melstock provide 12 beds in the West. Both wards are mixed sex accommodation. Admissions to Alumhurst are via the Admissions Assessment Unit, as per the Acute Care Pathway however admissions to the West of the county are direct into Melstock. All Organic Beds are currently provided at Alderney Hospital. There are 2 wards, Herm provides 23 beds; 18 of which are for female patients and 5 for male patients. St Brelades provides 17 male beds plus one for emergency use. The majority of patients are under the Mental Health Act section 2/3. Patients are admitted directly into both St Brelades and Herm Ward, although the 5 male beds on Herm are not for direct admissions but take transfers from St Brelades for patients almost fit for discharge Chalbury Unit (16 commissioned beds), Weymouth and Betty Highwood Unit, Blandford (12 commissioned beds) provided organic (dementia) beds in the West of the county but have had to be temporarily closed due to the shortage of registered permanently employed professionals. As a result there are currently no organic beds provided in the West of the county. Both of these units provided assessment and treatment for male and female patients. Both of these units are within the scope of this review and need consideration and decisions regarding inpatient provision The organic (dementia) beds at Alderney were originally configured to include a number of intensive treatment units for both male and female and assessment/treatment beds. Over the last two years the majority of patients have required intensive treatment and therefore there is no longer assessment/treatment and Intensive Treatment Unit (ITU) beds and the wards are now managing patients with high acuity requiring staffing levels of ITU. Year Ward Name to Dec FoT Herm St Brelades Grand Total Table 30. Admissions to Alderney Hospital by ward and year 66

67 22.6 Table 30 shows the number of admissions to Alderney wards in 2014/15, 2015/16 and 2016/17. The admissions to Herm ward are female admissions and admissions to St Brelades ward are male admissions. The admissions to Herm ward have fluctuated over the three years; whilst admissions to St Brelades ward are forecast to be highest in 2016/17. However, this data set is too small to identify any significant changes Table 31 shows admissions to Alderney by age group for 2014/15, 2015/16 and 2016/17. The highest number of admissions across the three years were from the age group (189), followed by (138). Admissions across the three years have remained relatively stable and it is difficult to draw any conclusions with a small data set. The Dorset Dementia strategy promotes living well with dementia. Actions to improve the rates of early diagnosis, reduce waiting times to diagnosis and improve support available in the community may result in the average age of admission to inpatient units rise as people live well for longer with dementia. Year Age Group to Dec FoT 3 year total <5 <5 <5 < Grand Total Table 31. Admissions to Alderney Hospital by Age Group. Locality to Dec FoT 3 yr total Central Bournemouth Christchurch Dorset West East Bournemouth East Dorset Mid Dorset North Bournemouth North Dorset Poole Bay Poole Central Poole North Purbeck <5 < Weymouth & Portland OOA 8 < GP Practice Code Not Known <5 <5 <5 5 Grand Total Table 32. Number of admissions to Alderney Hospital based on the locality of the patients GP 67

68 Alderney Admissions by Locality Chart 24. Number of admissions to Alderney Hospital based on the locality of the patients GP 22.8 Table 32 and Chart 24 show the number of admissions to Alderney Hospital based on the locality of the patients GP practice. Most admissions across the three years were for people registered with a GP in North Dorset, followed by Poole Bay, East Dorset, Poole Central and Christchurch. These localities have high populations of older people. Weymouth and Portland is next highest with 30 admissions across the three years. Fewest admissions were from Purbeck, Dorset West, North Bournemouth and Poole North Table 33 shows the number of admissions to Chalbury Unit in West Dorset by the locality of the patients GP. A large proportion of localities were not recorded in both years and this could change the picture of which localities have the most admissions. With this caveat in mind, the data shows that most admissions were from Mid-Dorset in both years combined (40) followed by Weymouth & Portland (31) and Poole Central (26). Further investigation into the admissions from Poole Central may reveal whether patients chose Chalbury over Alderney (which is closer); or whether Chalbury could better meet their needs; or whether Alderney didn t have vacancies; or other reason. Data for 2016/17 is not included because Chalbury Unit closed temporarily in 2015 for reasons described previously See section 25 for data on delayed transfers of care for Alderney Hospital. 68

69 Locality 2014/ /16 Central Bournemouth <5 Dorset West <5 7 East Bournemouth <5 East Dorset 5 Mid Dorset North Dorset 6 <5 Poole Central 26 Purbeck <5 Weymouth & Portland Not recorded Grand Total Table 33. Admissions to Chalbury Unit by locality during 2014/15 & 15/ The following case study gives an example of the support that can be offered by inpatient services: Mrs N is 85 years old and lives with her husband in Gillingham, Dorset. They have two daughters who visit regularly; however, Mrs N s main carer is her elderly husband. Mrs N was diagnosed with Dementia in Parkinsons in June 2016, since diagnosis Mrs N and her husband have been supported in the community by a Community Psychiatric Nurse. Early November 2016 the community team were advised that Mrs N was experiencing changes in behaviour which were causing her husband distress. Medications were reviewed and changed. After approximately a week further deterioration was noted and Mrs N threatened harm to herself and to her husband. Mrs N was experiencing delusional ideation and hallucinating. Mr N felt he could no longer cope and the team considered respite care, however Mrs N s behaviour had escalated to a point where hospital admission became necessary and she was admitted to Herm Ward, under Section 2 of the Mental Health Act on 11 th November On admission a full physical health check was undertaken and a physical health cause for the deterioration was excluded. Mrs N settled quickly on to the ward and was eager to participate in ward based activities. Mrs N s mobility was poor prior to admission and there was a noted improvement in her walking. Diet and fluid intake was also noted to have improved. Due to the reduced intensity of behaviours Mrs N s Section 2 was ended and she was placed under a Deprivation of Liberty Safeguard. The family attended regular multi-disciplinary team meetings during which they noted Mrs N s improvement and felt that on discharge from hospital a care home would be appropriate as a) they would struggle to provide care at home and b) Mrs N appeared to enjoy the sociable environment of hospital where she is stimulated through the day which has helped improve her sleep at night. A Social Worker was allocated to assist with finding a placement. During her hospital admission Mrs N became physically unwell with a chesty cold; this exacerbated her behaviour and Mrs N experienced an increase in episodes of hallucinating, her sleep deteriorated, she became prone to falling and her behaviour became increasingly aggressive. The cough was 69

70 treated but there remained deterioration in BPSD symptomology. Consultant Psychiatrist met with Mrs N s daughters to discuss the possible use of Risperidone medication to help alleviate Mrs N s symptoms, side effects were discussed and it was agreed to trial medication in Mrs N s best interest. Medication changes were successful and care homes were requested to review Mrs N with a view to placement. A care home close to her husband was located and they agreed to accept Mrs N. She was discharged early The community team visited Mrs N soon after discharge and talked with her and her husband. Both reported that Mrs N was settled and happy in the home and the home staff reported Mrs N had settled well in the home and was engaging well with fellow residents. The staff felt that they were managing Mrs N s care needs and had no concerns. 23. Acute Hospitals 23.1 There are three Acute hospitals in Dorset - Poole Hospital NHS Foundation Trust, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust and Dorset County Hospital NHS Foundation Trust Poole Hospital provides acute services for the local population of Poole, Purbeck and East Dorset, and is currently the lead provider for the Bournemouth, Poole and Christchurch conurbation for trauma, maternity, pediatrics and Ear, Nose, Throat services. Poole Hospital employs a specialist dementia nurse. They have adapted the environment of an older person inpatient wards to be dementia friendly and carry out advance care planning and end of life care planning for patients with dementia (PEACE), provide dementia awareness training for all their staff and provide dementia friendly food on its wards Royal Bournemouth and Christchurch Hospitals (RBCH) provides health care for the residents of Bournemouth, Christchurch, East Dorset and part of the New Forest with a total population of around 550,000, which rises during the summer months. Some specialist services cover a wider catchment area, including Poole, the Purbecks and South Wiltshire. The hospital gained Foundation Status in 2005, following three consecutive years as a three star performing trust. The catchment population is covered by two Clinical Commissioning Groups (CCGs): Dorset Clinical Commissioning Group and West Hampshire Clinical Commissioning Group RBCH has invested in an additional specialist dementia nurse and there is a dedicated older people assessment and liaison (OPAL) team consisting of specialist consultants, physiotherapists, occupational therapists (including Clinical Specialists) and nurses all trained in dementia care to assess people with dementia directly on admission to hospital. The Trust also has a multidisciplinary dementia strategy group. Over the last few years, the dementia strategy group has worked to develop simple changes which have transformed care for patients with dementia. These include: the introduction of orientation boards on wards, which tell patients what day it is, what ward they are on, and the names of staff looking after them large clocks more visible, clearer signage changed the colour of the toilet seats and automatic lighting in bathrooms. 70

71 23.5 Dorset County Hospital l provides a full range of district general services, including an accident and emergency department, and links with satellite units in five community hospitals. The hospital provides acute services to a population of around 250,000, living within Weymouth and Portland, West Dorset, North Dorset and Purbeck. They also provide renal services for patients throughout Dorset and South Somerset. Dorset County Hospital has approximately 400 beds, seven main theatres and two day theatres 23.6 Table 34 and chart 25 show that most admissions to hospital forecasted for 2016/17 for those with a primary diagnosis of dementia were registered with a GP in East Bournemouth, followed by Christchurch and Poole Bay. The number of admissions were higher in 2015/16 (390) compared with the other two years. North Dorset, East Dorset and Weymouth and Portland have the highest populations of over 65s pan-dorset so further investigation is needed into the relatively low number of admissions for North Dorset and Weymouth and Portland. Year Locality 2014/ / /17 FoT Bournemouth North Central Bournemouth Christchurch Dorset West East Bournemouth East Dorset Mid Dorset North Dorset Poole Bay Poole Central Poole North Purbeck Weymouth & Portland Unknown GP Prac Grand Total Table 34. Acute secondary care admissions for those with a primary dementia diagnosis by locality 71

72 Acute Admissions by Locality - Dementia / / /17 FoT Chart 25. Acute secondary care admissions for those with a primary dementia diagnosis by locality Year Dementia type 2014/ / /17 FoT Other Vascular Dementia Alzheimers Grand Total Table 35. Admissions by dementia type 23.8 Table 35 shows that most admissions were for people in the other category which includes: Dementia in other specified diseases classified elsewhere Unspecified dementia 23.9 The data shows that people with a primary diagnosis of Alzheimer s Disease are very unlikely to be admitted to hospital in contrast with people with a primary diagnosis of vascular dementia and Other types. Referring back to the dementia diagnosis table, most people within the other category were in Mid Dorset and Dorset West. People with a vascular dementia diagnosis were more evenly distributed by locality with a higher number in Mid Dorset. However, the reason for this variation in admissions could be due to the lack of information that the health care professional has about the patients diagnosis at the time of coding. Year Gender 2014/ / /17 FoT F M Grand Total Table 36. Acute admissions by gender 72

73 Year Age Band 2014/ / /17 FoT Under 65s <5 < Grand Total Table 37. Acute admissions by age group Tables 36 and 37 show that there were more admissions of people with a primary diagnosis of dementia for females than males and for those aged 65+ which would be expected based on dementia prevalence estimates The following data shows the use of acute services for people with a secondary diagnosis of dementia. There were a greater number of these admissions compared with admissions of people with a primary diagnosis of dementia, and most admissions across the three years were to Poole Hospital Trust followed closely by Royal Bournemouth and Christchurch Hospital (table 38). Table 39 shows that there were more admissions for females than males. Year Provider 2014/ / /17 FOT 3 year total PHT 1,621 1,586 1,716 4,923 RBH 1,687 1,656 1,573 4,916 DCH ,368 YDH SFT Other Table 38. Acute admissions for those with a secondary dementia diagnosis by provider Year Sex 2014/ / /17 FOT F 2,712 2,615 2,671 M 1,676 1,687 1,812 Grand Total 4,389 4,302 4,483 Table 39. Acute admissions for those with a secondary dementia diagnosis by gender Table 40 shows the categories of health problems that led to the admission for patients with a secondary dementia diagnosis. The most common reason for admission across the three years was for health problems related to the respiratory system (including pneumonia, lower respiratory disease, chronic obstructive pulmonary disorder); closely followed by the musculoskeletal system (including hip procedures); urinary tract and male reproductive system (including urinary tract infections and acute kidney injury) and cardiac surgery and primary cardiac condition (including myocardial infarction (heart attack) and arrhythmia (irregular heartbeat)). 73

74 23.13 Table 41 shows the ten most common secondary diagnoses for people admitted to hospital with a secondary dementia diagnosis. The main diagnosis was unspecified dementia, followed by vascular dementia and dementia in Alzheimer s disease. Admissions for patients with a primary diagnosis of Alzheimer s disease are very low compared with those with a secondary diagnosis. As the largest group, investigating and re-coding the unspecified dementia group could possibly change this top ten list. Year HRG Chapter Chapter Description 2014/ / /17 FOT D Respiratory System H Musculoskeletal System L W Urinary Tract and Male Reproductive System Immunology, Infectious Diseases and other contacts E Cardiac Surgery and Primary Cardiac Condition A Nervous System F Digestive System C Mouth Head Neck and Ears J Skin, Breast and Burns S Haematology, Chemotherapy, Radiotherapy and Specialist Palliative Care B Eyes and Periorbita K Endocrine and Metabolic System V Multiple Trauma, Emergency and Urgent Care and Rehab Hepatobiliary and Pancreatic G System Q Vascular System Female Reproductive System and M Assisted Reproduction U Undefined Groups <5 <5 36 R Diagnostic Imaging and Interventional Radiology 5 <5 0 N Obstetrics <5 0 0 Grand Total 4,389 4,302 4,483 Table 40. Reasons for admission by health group patients with secondary dementia diagnosis 74

75 Year Main Secondary Diagnosis 2014/ / /17 FOT F03X Unspecified dementia 2,591 2,438 2,475 F019 Vascular dementia, unspecified 1,132 1,119 1,032 F009 Dementia in Alzheimer's disease, unspecified F059 Delirium, unspecified F028 Dementia in other specified diseases classified elsewhere F002 Dementia in Alzheimer's disease, atypical or mixed type F023 Dementia in Parkinson's disease F067 Mild cognitive disorder F020 Dementia in Pick's disease F050 Delirium not superimposed on dementia, so described 1 29 Table 41. Top 10 secondary diagnoses for patients with secondary dementia diagnosis 24. Local authority dementia services 24.1 Local Authorities provide a range of support to try to help people live as independently as possible within their own homes, and continue to provide support and advice if residential care is required. If people are assessed as being eligible for adult social care they are provided with support to choose suitable care, and a financial assessment takes place to find out how much individuals can afford to pay towards their care For those who can no longer be supported within their own homes, due to either increasing physical needs or increased care requirements due to dementia, long-term residential placements are made. There is no longer a requirement by the Care Quality Commission (CQC) to register as a dementia home, so social workers and care managers assist clients, carers and families to choose the most suitable placement to fit people s needs In Bournemouth, in addition to this an accreditation scheme is in place; these accredited dementia homes are monitored by Bournemouth Borough Council to ensure that they are providing an environment and care especially suited to those living with dementia. Bournemouth council also pay two different rates for dementia; the DE2 rate recognises that as dementia progresses some people need additional 1-to-1 support, so a higher rate is paid The data below shows the number of placements made for those living with dementia across the three local authority areas, where the placement is funded by the local authority (tables 42-44). The highest number of placements in Dorset and Poole were in the age categories spanning For Bournemouth which has different age categories in the data, the highest number of placements are for the over 75s. Bournemouth also had the highest number of placements across both years combined (953); compared with Poole (278) and Dorset (226). More females than males were in placements across all three authorities. 75

76 2014/ DE1 2014/ DE2 2015/ DE1 2015/ DE2 Age Band Female Male Female Male Female Male Female Male under 65 <5 <5 0 0 <5 <5 <5 < < <5 < <5 < < Total Table 42. Long-term residential dementia placements Bournemouth Borough Council 2014/ /16 Total Age Band Female Male Female Male Female Male <5 <5 <5 <5 <5 < < <5 0 <5 0 Total Table 43. Long-term residential dementia placements Dorset County Council 2014/ /16 Total Age Band Female Male Female Male Female Male < < <5 0 Total Table 44. Long-term residential dementia placements Borough of Poole 24.5 For those living with dementia who continue to live at home and are cared for by an unpaid family member, the local authorities provide the opportunity for respite care. The data below shows the number of placements made for those living with dementia to provide respite for their unpaid carers, where the respite is funded by the local authority (tables 45-47). 2014/ DE1 2014/ DE2 2015/ DE1 2015/ DE2 Age Band Female Male Female Male Female Male Female Male under <5 < <5 0 Total <5 <5 Table 45. Dementia respite placements Bournemouth Borough Council 76

77 2014/ /16 Age Band Female Male Female Male <5 <5 < <5 <5 <5 < <5 <5 <5 < Total Table 46. Dementia respite placements Dorset County Council 2014/ /16 Age Band Female Male Female Male <5 <5 < < <5 <5 Total Table 47. Dementia respite placements Borough of Poole 24.6 Dorset County Council has funded a number of Dementia Innovations as part of the Partnership for Older People Programme (POPP) which are one-off seed funding opportunities that community groups can apply for. POPP has also been responsible (through the POPP Wayfinders, Champions and Community Development Workers involvement) for the start-up of a number of Dementia Friendly communities. Most recently, Go South West (inc. Moore Buses) will receive Dementia Friends Training for 1600 staff The Dorset County Council website provides a wide range of information and advice about care and support needs to help people stay safe and independent. A new dementia and memory loss hub is being developed as a directory for services, support groups and activities The Borough of Poole encompasses some 67,000 households and is home for 148,600 people. There is a recognised shortage of appropriate quality affordable care home beds with nursing provision. A Needs Assessment and report completed in 2008 and updated in 2011 established there was a clear shortage of suitable care home provision in the Borough for older people with dementia, now and in the future, due to the growing older population and increase in those with dementia. A subsequent report commissioned by the Council in early 2014 supported this assessment and reported on the changing demographics and resulting predicted care home needs for older people with high dependency needs. The outcome of this assessment is that there is significant under provision of affordable residential and nursing care for older people, particularly for people with dementia within the Borough of Poole. 77

78 24.9 The Borough of Poole Council is currently looking to provide an 80 bed care home facility on the development site at Mitchell Road, Poole which is designed to provide quality care at an affordable price. The care home will provide local residential care capacity including for those requiring nursing care and those with dementia or who have behaviours that challenge. The site is in an established residential area with a church, community centre, library and doctors surgery opposite. The area also has a well-established dementia friendly community. The development of this 80 bed care home in Poole will ultimately increase the opportunity for local residents to live in a care home in Poole near their friends and family. The focus will be that this is the individual s home and will accommodate individuals with a range of residential and nursing needs. The Borough of Poole s Service Improvement Team and contract management arrangements will monitor and support the home to deliver good quality care with a strong person-centred approach. Planning permission was approved in March 2017 and the local authority is currently tendering for the build contractor and care provider Bournemouth, Dorset and Poole Local Authorities jointly commission an out of hours emergency social care service with a remit to keep service users safe until next working day. This includes people with dementia. There is a lack of resources in the community to support their work; for example out of hours emergency residential placements or domiciliary care. The service doesn t record whether a service user has dementia so service use data is not available. As mentioned previously, the Crisis Service linked with the Community Mental Health Teams does not support people with dementia Issues with respite care include carers not being able to book a respite bed in advance with assurance that the person will get a bed in a home they may be familiar with. This creates reluctance to make plans in case a bed is not available. If using home care to have a short break, the inconsistency of staff can make carers reluctant to use it, but this would also apply to packages of care The Dementia Directory is a directory of services, support and sources of information for patients and carers. It contains information on the dementia pathway including receiving a diagnosis of dementia, legal information, adult social care, staying healthy, care homes and end of life care. There is national and local information on carers, support groups and services. Currently the directory is being reviewed and the new version will be available on the Dorset CCG website Table 43 shows the estimated number of people with dementia aged 65 and over living in a care home with or without nursing by local authority/ non-local authority and age, projected to This is based on ONS data provided by Poppi and the estimate from the Dementia UK Update 2014 that 69% of people in care homes have dementia Of people with dementia living in care homes, most people are not local-authority funded. In 2015, most care home residents with dementia lived in Dorset (2148); followed by Bournemouth (1162) and Poole (778) and most were age 85+. The population is expected to increase by 52% by 2030 (an increase of 2122 people pan-dorset) (table 48). 42 Poppi Information System. Available online np=1 Accessed

79 Dorset % change yrs - LA care home with or without nursing yrs- LA care home with or without nursing yrs- LA care home with or without nursing yrs- non-la care home with or without nursing yrs- non LA care home with or without nursing 85+yrs- non LA care home with or without nursing Total population aged 65 and over living in a care home with or without nursing Bournemouth 65-74yrs- LA care home with or without nursing 75-84yrs- LA care home with or without nursing yrs- LA care home with or without nursing yrs- non LA care home with or without nursing 75-84yrs- non LA care home with or without nursing 85+yrs- non LA care home with or without nursing Total population aged 65 and over living in a care home with or without nursing Poole 65-74yrs- LA care home with or without nursing 75-84yrs- LA care home with or without nursing yrs- LA care home with or without nursing yrs- non LA care home with or without nursing 75-84yrs- LA care home with or without nursing 85+yrs- non LA care home with or without nursing Total population aged 65 and over living in a care home with or without nursing Total of Bournemouth, Dorset and Poole Table 48. Estimated number of people in care homes with dementia projected to

80 25. Delayed transfers of care 25.1 Locally, the acute providers, Poole Hospital and RBCH Foundation Trusts have recently reported fluctuation and general increases in inpatient stays of thirty days plus, which continue to follow an upward trend. The data are not condition specific so delays cannot be directly attributable to patients with dementia What is known, both locally and nationally, is that one in four patients admitted to an acute hospital is likely to have dementia (Kings Fund 2011). Most acute hospitals have a frailty unit and, although there is limited capacity, these units provide an opportunity to identify the risks attached to patients by a prolonged stay. Patients with dementia are potentially at risk of delay in their transfer of care Discharge of patients with dementia is a complex area. The care and support planning stage needs to be very current so providers know the patient s level of ability and exactly what care they need to provide, how and in what time period If the patient is unable to reliably communicate their level of ability pre-admission, medical staff are often reliant on third party information. For health professionals it can be very difficult to know what level of recovery might be possible if information is incomplete on pre-admission ability. Both health and social care assessments are undertaken in an artificial institutionalised environment where the patient with dementia may present as more confused, bewildered and dependent, which will influence assessments of communication, mobility, self-care and self-medication. The multidisciplinary team s joint risk assessment will reflect additional needs and risks that could give a false picture of a patient s needs at home with the result being that care and support is overcompensated for in planning a return home It is accepted nationally that both medical and social care staff have a general lack of understanding of what services are available in the community and, in particular, of new developments Tables 49 to 51 give information about delayed transfers of care for patients of Herm and St Brelades wards at Alderney Hospital between and Local authority Number of patients Number of days delayed total Average delayed days per patient Most delayed days Least delayed days Bournemouth Poole Dorset Total Table 49. Delayed transfers of care for patients at Alderney Hospital Herm and St Brelades wards between and

81 Gender Male 9 Female 8 Table 50. Gender of patients with delayed transfers of care (Alderney Hospital Herm and St Brelades wards between and ) Ward Herm 12 St Brelades 5 Table 51. Wards that recorded delayed transfers of care (Alderney Hospital Herm and St Brelades wards between and ) 25.7 Table 49 shows that 17 patients experienced a delayed transfer of care in the time period, and that the average delayed days per patient was 54. The most number of delayed days experienced by any one patient was 143 (Bournemouth); the least was 2 (Dorset). Poole had the most number of patients delayed (8) and the highest average number of delayed days per patient (63). Dorset had the lowest average number of days delayed per patient (41) and the most days delayed was only There was a fairly even balance of males and females experiencing delayed transfers of care and most patients were at Herm ward (12) (tables 50 and 51). Sixteen of the 17 patients were delayed due to awaiting a nursing home placement. The remaining one person was delayed due to awaiting a care package in their own home. All but one of the delays was attributed to both the NHS and the Local Authority; the remaining one delay was attributed to the NHS. 26. Section 117 aftercare 26.2 Some people who have been kept in hospital under the Mental Health Act have a statutory right to paid help and support after they leave hospital. The law that gives this right is section 117 of the Mental Health Act, and it is often referred to as 'section 117 aftercare'. The English and Welsh Codes of Practice have examples of what sort of things might make up aftercare services under section 117. These include: healthcare social care and employment services supported accommodation services to meet social, cultural and spiritual needs as long as they meet a need that arises from or is related to a mental condition and help reduce the risk of a mental condition getting worse Table 53 shows the number of people in receipt of section 117 aftercare funding with a dementia diagnosis and in residential care between 2014/15 and 2016/17 and the associated costs. The number of placements in Poole remained the same across the three years; whereas the number of placements increased by 24% in Bournemouth and 13% in Dorset. The total cost of placements in 2016/17 was just over 8 million pounds. 81

82 Bournemouth Poole Dorset Total Number of placements Cost to CCG 606, ,019 1,330,571 2,556,133 Cost to LA 1,194,378 1,222,853 1,634,045 4,051,277 Total cost 1,800,922 1,841,872 2,964,616 6,607,410 Average placement cost to CCG 17,840 25,792 14,155 16,817 Average placement cost to LA 35,129 50,952 17,383 26,653 Total average placement cost 52,968 76,745 31,538 43, Bournemouth Poole Dorset Total Number of placements Cost to CCG 724, ,343 1,653,739 3,123,254 Cost to LA 1,217,315 1,256,545 2,104,115 4,577,975 Total cost 1,941,488 2,001,888 3,757,854 7,701,229 Average placement cost to CCG 20,116 31,056 14,506 17,950 Average placement cost to LA 33,814 52,356 18,457 26,310 Total average placement cost 53,930 83,412 32,964 44, Bournemouth Poole Dorset Total Number of placements Cost to CCG 825, ,451 1,608,638 3,305,272 Cost to LA 1,289,768 1,352,367 2,097,061 4,739,196 Total cost 2,114,951 2,223,818 3,705,700 8,044,468 Average placement cost to CCG 19,647 36,310 15,176 19,217 Average placement cost to LA 30,709 56,349 19,784 27,553 Total average placement cost 50,356 92,659 34,959 46,770 Table 53. Section 117 aftercare funding and in residential care for people with a dementia diagnosis, 2014/15 to 2016/17. 82

83 27. Workforce 27.1 Table 54 shows the number of staff by staff group, service and site for the Memory Assessment Service (MAS), Older People s Community Mental Health Teams (CMHT), Inpatient services at Alderney and the Intermediate Care Service for Dementia (ICSD) effective on 28 th February The biggest staff group across all services was Additional Clinical Services followed by Nursing and Midwifery Registered. The older people s inpatient service at Alderney employed the most staff of all services, and the biggest staff group at Alderney was Additional Clinical Services. The Memory Assessment Service employed the least number of staff and most of these were based at Alderney Hospital in Poole. Service Site Name Additional Clinical Services Administrative and Clerical Allied Health Professionals Nursing and Midwifery Registered MAS Alderney Hospital Atrium Health Centre Blandford Comm Hosp Bridport Comm Hospital Westminster Memorial Hospital 1 1 Weymouth Comm Hosp MAS Total Older People CMHT 1a Acland Rd Dorchester 2 2 Alderney Hospital Ashley Elm House 1 1 Atrium Health Centre 6 6 Blandford Comm Hosp 2 2 Bridport Comm Hospital Christchurch Fairmile House Forston Clinic Kings Park Hospital Oakley Bungalow 1 1 Oakley House Westminster Memorial Hospital Weymouth 1 1 Weymouth Comm Hosp Yeatman Hospital OPMH CMHT Total OPMH Inpatient (Alderney) Total ICSD Alderney Hospital Weymouth Comm Hosp ICSD Total Grand Total Grand Total Table 54. Numbers of staff by group and site name for Dorset HealthCare services included in the dementia review. Effective date 28 th February

84 27.2 The staff ratios for Herm and St Brelades wards at Alderney Hospital are 3 registered nurses to 7/8 unregistered staff on an early and late shift and 2 registered nurses to 6 unregistered staff on a night shift; for each ward. This assumes a level of acuity for patients which may vary depending on the number of patients and levels of observations. A further ward manager is required with the support of a Band 6 clinical coordinator to allow for the acute care pathway to function and therefore reduce the length of stay. In addition, therapy staff are required in order to provide physiotherapy and occupational therapy. For both wards therapy required includes:- Physiotherapy 0.5 Occupational Therapy 4 WTE Tech 2 WTE Team leader Dietician 0.2 WTE Grouping 2014/ / /2017 Sum of LTR (FTE) Sum of LTR (Headcount) Sum of LTR (FTE) Sum of LTR (Headcount) Sum of LTR (FTE) ICSD 18.98% 18.75% 15.34% 16.81% 7.09% 7.21% Sum of LTR (Headcount) MAS 3.32% 5.22% 3.24% 4.24% 23.56% 21.56% OPMH CMHT 13.97% 13.26% 7.05% 6.72% 5.81% 5.92% OPMH Inpatient 10.67% 10.07% 3.67% 3.40% 12.33% 12.35% (Alderney) Grand Total 12.43% 11.87% 6.34% 6.21% 10.01% 10.03% Table 55. Staff turnover rate, Dorset HealthCare services. Key: LTR- Labour Turnover Rate FTE - Full Time Equivalent Headcount - actual number of people 27.3 Turnover is the number of substantive staff who left the trust voluntarily in the reporting period expressed as a percentage of the average headcount in the period. Average headcount is the average of permanent staff headcount at the start of the reporting period and permanent staff headcount at the end of the reporting period. Table 55 shows the turnover for staff in four Dorset HealthCare services for 2014/15, 2015/16 and 2016/17. The ICSD had the highest turnover of the four services in the first two years. The MAS had the highest turnover of the four services in 2016/17. The high turnover in 2014/15 within the ICSD and subsequent reduction in later years could be because it was a new service which may have taken time to bed in Chart 26 shows the proportion of staff that leave (turnover) and join NHS staff groups in England, between August 2012 and November The turnover rate (leaving rate) has peaks and troughs between 0.62% and 1.7% which is much lower than the rates for Dorset HealthCare services 43 The Health Foundation / Nuffield 84

85 in table 55 which range between 6.21% and 12.43%. The variation could be due to chart 26 including all NHS staff groups compared with table 55 which is staff groups working with older people / dementia. Chart 26. Proportion of staff that leave / join the NHS Service 2014/ / /17 3 year average ICSD 7.61% 6.70% 5.81% 6.71% MAS 3.59% 5.70% 3.13% 4.14% OPMH CMHT 5.27% 4.96% 4.62% 4.95% OPMH Inpatient (Alderney) 6.61% 7.89% 7.80% 7.43% Grand Total 5.97% 6.39% 5.95% 6.11% Table 56. Absence rate, Dorset HealthCare services 27.5 The absence rate is FTE days lost divided by FTE days available expressed as a percentage. Table 56 shows that the absence rate overall has not varied widely in the three year period. Staff employed within the older people s inpatient services at Alderney had the highest absence rate across the four services (7.43%); MAS had the lowest absence rate (4.14%). 85

86 27.6 Between April and June 2016 the average sickness absence rate for the NHS in England was 3.93 per cent, almost the same as the same period in The North West Health Education England (HEE) region had the highest average sickness absence rate at 4.54 per cent. North West London HEE region had the lowest average at 3.11 per cent. The Wessex region rate was 3.69 per cent. Healthcare Assistants and Other Support Staff were the staff group with the highest average sickness absence rate with an average of 6.00 per cent. Nursing, Midwifery and Health Visiting Staff had an average sickness rate of 4.58, and Administration and Estates 3.46 per cent. Amongst types of organisation, Ambulance had the highest average sickness absence rate with an average of 5.00 per cent. Commissioning Support Units had the lowest average with a rate of 2.60 per cent. Community Provider Trusts had an average rate of 4.34 per cent The absence rate for the four services in table 56 is higher than the Wessex and England averages. Service 2014/ / /17 Sum of Rate (all) Sum of Rate (all) Sum of Rate (all) ICSD 16.43% 9.33% 16.13% MAS 15.48% 6.13% 0.66% OPMH CMHT 6.18% 4.82% 4.70% OPMH Inpatient (Alderney) 4.40% 7.10% 14.00% Total 7.31% 6.37% 10.10% Table 57. Vacancy rate, Dorset HealthCare services 27.8 Table 57 shows the vacancy rate for four Dorset HealthCare services in 2014/15, 2015/16 and 2016/17. The total rate for all four services has increased during this time from 7.31% to 10.10%. The ICSD has had the highest vacancy rate across the three years. The older people CMHT had the lowest rate across the three years. The MAS rate has had the most change from 15.48% in 2014/15 to 0.66% in 2106/ There is an increasing difficulty in recruiting and retaining registered professionals to work within dementia inpatient services partly due to the older population profile of Dorset there are fewer people of working age than the national average. The rural areas of Dorset are less attractive for potential employees than the larger towns. The acuity of patients has increased over time and the patient groups now being admitted are deemed to require intensive support unit levels. 44 NHS Digital. NHS Sickness Absence Rates April 2016 to June Available online: Accessed

87 27.10 The following points explain some of the differences between Mental Health and other areas of care 45, which could impact on workforce indicators such as those in this section. Mental Health services require a higher proportion of interventions Interventions are often reactive and unplanned Higher proportion of service users are ambulatory rather than bed based Length of stay in hospital tends to be longer for Mental Health service users Higher percentage of service users are detained rather than there by choice Around half service users require a higher degree of security. 45 NHS England (2015). Mental Health Staffing Framework. Available online Accessed

88 28. Summary 28.1 The Prime Ministers Challenge on Dementia 2020 is a five year vision aimed at positioning England as the best country in the world for dementia care and research by The 2020 challenge recognises the growing body of evidence on the profound impact dementia is having on society. While it celebrates the significant progress made to date it also acknowledges that much more still needs to be done. Goals within this challenge are measurable improvement on all areas of the Prime Minister s challenge on dementia 2020, including: o o o maintain a diagnosis rate of at least two thirds; increase the numbers of people receiving a dementia diagnosis within six weeks of a GP referral; and improve quality of post-diagnosis treatment and support for people with dementia and their carers Dorset is a county comprising both rural and urban areas and has a GP registered population of 793,496 (on ). The large towns are Poole, Bournemouth and Weymouth and Portland. The rural west has a low population density Dorset and Poole have a higher proportion of over 65s than the England average, with Bournemouth being similar to the England average. The over 65 population pan-dorset is forecast to increase from 24% of the population in 2015 to 30% by The over 65 population in mainly rural localities is 28%, compared with urban city and town areas (21%). North Dorset, East Dorset, Weymouth and Portland and Christchurch have the largest populations of over 65 year olds pan-dorset Dorset has a very low population of people from black and minority ethnic (BME) backgrounds. In England and Wales, 8% of over 65s are from BME backgrounds compared with just 0.7% in Dorset. Most BME people live in Bournemouth (1.3%); Dorset has the lowest population at 0.4% The Dementia UK update (2014) estimates that 7.1% of the over 65 population nationally has dementia. This estimate is based on a number of research studies into dementia prevalence, including the Cognitive Functioning and Ageing Studies II which estimates that 6.4% of the over 65 population have dementia. NHS England has adopted the findings of the Cognitive Function and Ageing Studies II in setting the dementia diagnosis target for CCGs however many recognise the need for a more refined calculator that adjusts for demographics Research estimates that dementia is an age related disease present in approximately 0.9% of people aged 60-64; increasing to 41.1% of those aged % of people with dementia are female. 54% of people with dementia have a mild form of the disease; 32% have moderate dementia and 12.5% have severe dementia. The most common type of dementia is Alzheimer s (62%); followed by Vascular Dementia (17%) and Mixed Dementia (10%) Risk factors for dementia include age, gender, vascular health, diabetes and education. Women are more at risk of developing Alzheimer s Disease and early research suggests a link with hormonal changes around the menopause, with HRT being a protective factor. Men are more at risk of developing vascular dementia due to higher rates of poor vascular health. Rates of coronary heart disease, stroke and transient ischaemic attack (mini-stroke) are higher for Dorset than the Wessex region and England averages; these are health conditions associated with increasing age and could be explained by the older population of Dorset. The rate of diabetes is similar to the regional and England average. The more years spent in education the lower the risk of developing dementia; however this appears to be associated with people being more able to compensate for changes in 88

89 their brain functioning as opposed to not developing dementia in the first place. Dementia services may need to support people to improve their health to reduce the impact of co-morbidities such as these on dementia; and services for people with coronary heart disease, stroke, TIA, hypertension and diabetes may benefit from being able to identify early signs of dementia, having the skills to support people with a dual diagnosis including dementia and being part of the dementia pathway People from BME backgrounds are at greater risk of developing dementia and at an earlier age than the general population. Research suggests this may be due to poorer vascular health; unfamiliarity with the disease due to a lack of older relatives living in this country; the stigma surrounding mental health issues; unfamiliarity with services and a cultural that values looking after relatives at home. The research recommends the commissioning of community dementia navigators that represent this population and delivering Race Equality and Cultural Competency training for health and social care staff. People with developmental disabilities are also at increased risk of developing dementia, especially people with Down s Syndrome The Index of Multiple Deprivation measures deprivation through seven categories in smallgeographical areas. People living in areas of deprivation are more likely to experience poorer health outcomes and a lower life expectancy than those living in less deprivation. The link between poor vascular health and dementia means it can be assumed that people living in areas of deprivation are at greater risk of developing dementia Weymouth & Portland and Bournemouth experience the highest levels of deprivation (of pan-dorset localities). Apart from these two localities Dorset has low levels of deprivation; the least deprived localities are East Dorset and Christchurch. There may be an increase in dementia prevalence in areas with more deprivation due to the links between dementia and vascular health, diabetes and education. Weymouth and Portland, Bournemouth and Purbeck rank in the worst of pan-dorset localities for overall deprivation, education skills and training and health deprivation and disability. Purbeck has a small over 65 population and so the impact of deprivation will be less than in Weymouth & Portland and Bournemouth where there are larger over 65 populations. Poor vascular health, diabetes and education are modifiable risk factors. There may be a benefit to including services that support and promote health such as public health and the NHS in dementia pathways especially in the areas with greater deprivation Dorset has a higher life expectancy at birth (LE) and at age 65 for males and females than the South West region and England averages (LE is 85 and 81.5 respectively). However, healthy life expectancy, which is the number of years a person would expect to live in good health based on contemporary mortality rates and prevalence of self-reported good health; is lower for females than males (65.2 and 67), and the female rate pan-dorset is equal to the South West and England averages whereas the pan-dorset male rate is higher. This may be a reflection of factors such as females living longer than males; the increased likelihood that females will be carers for other relatives or a partner; and the increased risk of developing Alzheimer s disease Research suggests that 61% of people with a dementia diagnosis had three or more other health diagnoses; with pneumonia, urinary tract infections and congestive cardiac failure accounting for two-thirds of preventable admissions in those with a dementia diagnosis. In addition to the impact on the person with dementia, co-morbidities such as these place an increasing burden on carers Early-onset dementia (EOD) occurs before the age of 65 and is estimated to be prevalent in 0.9% of year olds. Additional impacts for people with EOD and their families include the interruption to the stage of life; issues with employment; family life; household resources and support; the duration of the disease and difficulties in diagnosis. 89

90 28.14 The mortality rate from dementia pan-dorset is similar to the England average of people per thousand population (all ages) or 720 people per thousand population 65+. This means that pan- Dorset in 2015/16 around 1,144 people died of a dementia related cause In January 2017, Poole had a dementia diagnosis achievement rate of 79.8%, Bournemouth 77.6% and Dorset 57.7%. The rate is the prevalence of dementia age 65+ (6.4%), the number of people on the GP practice register, and the percentage of those diagnosed. The national target is 66.7% achievement. The worst performing locality is West Dorset (39.1%) followed by North Dorset (56.3%). The best performing of Dorset localities are Weymouth and Poole (64.1%) and East Dorset (62.5%) however they are still both below the target. Bournemouth North is also below the target at 62.5% The Memory Gateway is the pathway through which people are referred or can self-refer for help if they are worried about their memory. This includes the Memory Support and Advisory Service (MSAS) provided by Alzheimer s Society and the Memory Assessment Service (MAS) provided by Dorset HealthCare Both pre- and post-diagnostic referrals to the MSAS were at 6,214 in 2015/16 and are forecast to increase to 6,346 by the end of 2016/17. The forecast suggests that most referrals will come from Christchurch, followed by East Dorset and then Weymouth and Portland. Localities with the fewest referrals will be Mid Dorset, Poole North and Central Bournemouth. Localities with the most referrals also have the highest population numbers of over 65s. The rate of referrals per 1000 population is below the CCG average in Mid Dorset, North Dorset, East Dorset, Poole North and Weymouth and Portland. Weymouth and Portland has a large population of people over 65 and relatively high deprivation and so a higher referral rate would be expected. North Dorset and East Dorset also have high numbers of people over 65 and therefore more referrals to the MSAS would be expected Referrals to the MAS service numbered 2,129 in 2015/16 and are forecast to reach 2,132 in 2016/17. In 2016/17, most referrals are expected to come from Weymouth and Portland, North Dorset and East Dorset. Fewest referrals are expected to come from Central Bournemouth, North Bournemouth and East Bournemouth. North Bournemouth locality is under-performing against the dementia diagnosis target and has an average proportion of over 65s, however Bournemouth as a whole is exceeding the target. The MAS referral pattern is similar to the MSAS service in that the highest referrals are from localities with high numbers of over 65s There were 1,018 MAS dementia diagnoses in 2015/16 and forecast to be 1,631 diagnoses in 2016/17. Most notably, there were high numbers of referrals from Weymouth and Portland to the MSAS and MAS but very low number of dementia diagnoses. Localities with the highest dementia diagnoses forecast for 2016/17 were East Bournemouth, Poole North and North Dorset Alzheimer s Disease is the most common type of dementia diagnosed, with the highest numbers in Christchurch and Dorset West. Less common types of dementia include dementia with Lewy bodies, dementia in Parkinsons Disease, Frontotemporal Dementia, Creutzfeldt-Jakob Disease, Mixed Dementia, Huntington s Disease and Wernicke-Korsakoff Syndrome. Services should meet the needs of people with these types of dementia including considerations for those with earlyonset dementia. 90

91 28.21 The dementia mortality rate applied to the population of Dorset would have resulted in 1,144 dementia related deaths in 2015/16; more than the number diagnosed by the MAS in the same year (1,018) As a result of a previous review of the Older People Mental Health services in the East of the county the number of beds were reduced and services developed to provide care closer to home with the development of the Intermediate Care Service for Dementia (ICSD). The inpatient services in the West of the county are currently closed due to a lack of a registered workforce. The highest localities for admissions to the now closed Chalbury Unit were from Weymouth & Portland and Mid- Dorset. Alderney hospital in Poole is now the only inpatient service in Dorset for people with dementia. In 2015/16 there were 122 admissions to Alderney Hospital, and the forecast for 2016/17 was 152. Most admissions to Alderney Hospital across the three years since 2014/15 were from North Dorset (57) followed by localities in the East (Poole Bay, 54; East Dorset, 44; Poole Central, 37; Christchurch, 34). In 2016/17 most admissions are expected to be from localities in the East. However, localities in the West (including North Dorset) are expected to admit 50 people to Alderney in 2016/17, suggesting a need for services in the West The most common reasons for admission to an acute hospital for people with a secondary diagnosis of dementia were for health problems related to the respiratory system (including pneumonia, lower respiratory disease, chronic obstructive pulmonary disorder); closely followed by the musculoskeletal system (including hip procedures); urinary tract and male reproductive system (including urinary tract infections and acute kidney injury) and cardiac surgery and primary cardiac condition (including myocardial infarction (heart attack) and arrhythmia (irregular heartbeat)). Most admissions were from localities in the East of Dorset to Royal Bournemouth and Christchurch Hospital and to Poole Hospital Local authority services include long-term dementia residential placements, dementia respite beds, day services and support groups the latter for people with dementia and carers. Delayed transfers of care between hospital and community services are caused by many factors including communication, availability of community placements and the ability to develop accurate assessments of people s future needs to enable independent living. Local authorities are planning for an increasing demand for dementia placements The process of gathering the data and information for this report has highlighted the lack of a consistent approach across services in Dorset in recording dementia diagnosis and addressing this could be beneficial for the future modelling and monitoring of services According to the majority of the service data, the greatest predictor of service use has been age, and therefore future modelling of services should take into account the geography of Dorset based on proportion of the over 65 population. Attention should also be focussed on the needs of minority groups including people with learning disabilities and black and minority ethnic communities to ensure that they are not further disadvantaged in being able to access services in the future Areas to be addressed in future modelling of services include: The low dementia diagnosis rate in Dorset of 57.7% The low dementia diagnosis rate in West Dorset (39%) and North Dorset (56%) The low referral rate to the MAS service from North Bournemouth, which is also performing poorly on dementia diagnosis rates. The contradiction in the number and locality of referrals to the MSAS and MAS compared with the number and locality of diagnoses, particularly the low number of diagnoses for Weymouth 91

92 and Portland; which has a large over 65 population and a high rate of deprivation. The majority of the Memory Assessment Service staff are based in Poole which may explain the higher diagnosis rates in the East. The highest proportion BME 65+ population is in Bournemouth; and North Bournemouth is under-performing against the dementia diagnosis target. However the whole of Bournemouth is over-performing and has a relatively average proportion of over 65 population (all ethnicities); therefore there is a risk that the BME over 65 population in Bournemouth could be overlooked when modelling services. The lower healthy life expectancy for females in Dorset compared with males in Dorset and compared with males and females in Poole and Bournemouth. This may be linked with the lower dementia diagnosis rate in Dorset assuming that females are living with dementia without the support that accompanies a diagnosis; and suggests a need for services designed to support females in Dorset to live well for longer; whether they have dementia themselves or are caring for someone with dementia. The need for health and social care services to work together in a more coherent way to reduce delayed transfers of care and further develop the market for dementia care. There may be a benefit to including services that support people with co-morbidities including coronary heart disease, stroke and diabetes in dementia pathways especially in the areas with higher numbers of vascular dementia diagnoses such as Mid and North Dorset. 92

93 Appendix 1. Memory Gateway pathway 93