Thames Valley Strategic Clinical Network

Transcription

1 Thames Valley Strategic Clinical Network Commissioning Guidance 2015/16

2 Principles Consideration of the whole patient pathway regardless of who commissions it Integration of mental health for physical health conditions Use of the House of Care model Partnership working

3 Perinatal mental health By Thames Valley CCG: Specialist Community Perinatal Mental Health Services as determined by the Maternal Mental Health Alliance (MMHA) July 2014 Aylesbury Vale Bracknell And Ascot Chiltern Milton Keynes Newbury And District North & West Reading Oxfordshire Slough South Reading Windsor, Ascot And Maidenhead Wokingham

4 Perinatal mental health Background No county has an established specialist perinatal mental health service that fulfils guidance requirements (see diagram) Training of maternity and primary care staff in perinatal mental health is highly variable within and across counties/ccgs The available specialist inpatient facilities in Hampshire are underused with mothers who have a primary diagnosis of puerperal psychosis admitted to other hospitals in Thames Valley SCN recommendations: 1. For maternity service providers they should ensure that; All midwives are trained and feel confident to; Ask the right questions to detect mental health problems prenatally and postnatally Know when to refer and how and who to refer to They have an identified specialist mental health midwife They have evidence of a continuing educational development programme in perinatal mental health available to all staff 2. For CCGs: Each CCG should ensure their population has; Access to an identified perinatal mental health service which follows national guidance and has at its core minimum A Consultant Perinatal Psychiatrist One or more perinatal community psychiatric nurses. Access to a mother and baby unit for all cases where the mother needs to be admitted Primary care staff (General practitioners and Health visitors) who feel confident to Ask the right questions to detect mental health problems prenatally and postnatally Know when to refer and how and who to refer to Evidence of a continuing educational development programme in perinatal mental health available to all primary care staff. And that they commission their services to be compliant with NICE guidance

5 Paediatric Palliative Care CCG Patients Helen and Douglas House Nights H and D House Patients Wessex Hospice Nights Wessex Total patients both Hospices Total Nights Tariff at 30% costs OXFORDSHIRE CCG ,540 CHILTERN CCG ,110 AYLESBURY VALE CCG ,930 WINDSOR CCG ,340 NEWBURY AND DISTRICT CCG ,160 WOKINGHAM CCG ,710 NORTH & WEST READING CCG ,350 SLOUGH CCG ,330 SOUTH READING CCG ,580 MILTON KEYNES CCG ,360 BRACKNELL AND ASCOT CCG ,410

6 Paediatric Palliative Care Background There is significant inequity in the commissioning, and access to children s hospice based palliative. Adult care is funded on a ratio of 85:15 public sector: charitable funding, children s care historically on a ratio of 15:85 but in Thames Valley 0:100 By contrast there is a standard agreement covering the former South West SHA that contributes c.30% cost as do Gloucestershire and Nene CCGs. The current position in TV is that the children with the highest medical needs receive no funding from the NHS for their palliative care. This is an inequitable and unsustainable position. SCN recommendation CCG should commission and fund Children s Hospice Based palliative care to a level similar to other CCGs (c. 30% actual costs through a staged process) as an interim funding solution until national palliative care currencies are fully developed.

7 CAMHS Year 2013/14, Tier 2 & 3

8 CAMHS Background CAMHS has a high place on the national agenda with abundant evidence that early treatment and prevention services work and are cost effective. SCN recommendations Commissioners should prioritise CAMHS as a joint commissioning initiative across agencies to ensure integrated provision in all areas. Commissioners should adopt an invest to save strategy with a focus on Tiers 1 and 2. There is a clear need for investment in the provision of children and young people in crisis. Paediatric liaison psychiatry services should be commissioned to be available to all acute paediatric units. The first priority must be to establish a robust clinical emergency service with weekend and bank holiday capability. Resolve status of Berkshire Healthcare Trust Adolescent Unit

9 Transition from children to adult services Background Improving the transition of young people from paediatric to adult services has high profile nationally across 4 workstreams CAMHS, Special educational needs, Long term conditions, Specialised Commissioning. SCN recommendations that CCGs should ensure that; Each provider has a transition policy Each of their providers has an identified Health Professional responsible for transition and a Board lead for transition Each provider is required to supply evidence of compliance with You re welcome - Quality criteria for young people friendly health services

10 Childhood Asthma Emergency admission - Asthma Data source: CHIMAT as at April 2014

11 Childhood Asthma Background UK has one of the highest prevalence rates of asthma symptoms in children worldwide with 1.1 million children in the UK currently receiving treatment for asthma. It has been estimated that as many as 90% of deaths from asthma are preventable. Asthma UK conducted a Compare your care survey in 2013 which revealed that only 1 in 4 people with asthma had been given an asthma action plan yet data shows that patients who use an asthma action plan are 4 times less likely to have an attack that requires emergency hospital treatment. SCN work TVSCN are working with GP Facilitators across Buckinghamshire/Oxon, Berkshire and Milton Keynes to; aid the full implementation of NICE QS25 Quality standards for asthma (Issued Feb 2013) aid the implementation of British Guidelines on the management of asthma (BTS/SIGN) provide specific emphasis on self-management education and personalised action plans in CYP encourage use of management strategies for recurrent viral wheeze in young children Commissioning Intentions In line with patient centred care and self-management, all children and young people with an asthma or viral wheeze diagnosis should have a written personalised asthma action plan. As a development from the TV Children & Maternity SCN, Clinical Director, Anne Thomson who sits on the NHS England s Clinical Reference Group on Paediatric Medicine, NHS England are developing a Best Practice Tariff for Paediatric Asthma for implementation in 2016/17. This will follow a similar vein to how the paediatric diabetes best practice tariff is defined and implemented.

12 Cancer Early Diagnosis Staging The target of staging completeness is 75% for solid tumours, the national average is 59%; Thames Valley is very low and has a wide range between 23.6% and 52.6% across CCGs Diagnosis at an early stage of the cancer's development leads to dramatically improved survival chances. An indicator on the proportion of cancers diagnosed at an early stage is, therefore, a useful proxy for assessing improvements in cancer survival rates. Data source: Cancer Commissioning Toolkit

13 Cancer Early Diagnosis Background Improving GP access to diagnostic testing for suspected cancer ensuring direct access for specific tests focusing on the Best Practice Commissioning pathways for early detection: lung, colorectal and ovarian cancers. Chest radiography (CXR) is advocated as the best first line test for suspected lung cancer (MBUR-7). NICE 2005 guidelines describe high-risk symptom patterns warranting CXR. Although direct access to chest X-ray services for GPs is already available, data shows a variability in requests for chest X-rays across the country and many people with lung cancer continue to be diagnosed at a late stage. Ovarian Cancer - although often referred to as the silent killer, recent evidence has shown that patients with ovarian cancer present to GPs with symptoms that if investigated earlier would allow earlier diagnosis. Recently published NICE guidance has updated and clarified the symptoms which would warrant further investigation by GPs. Emergency presentations for colorectal cancer remain high (25%), only 26% are diagnosed through the urgent GP (two week wait) referral process (29). It is recognised that earlier diagnosis of cancers, particularly colorectal cancer, can significantly increase chances of survival. The availability of direct access to flexible-sigmoidoscopy for GPs is currently variable SCN Recommendation Commissioners should ensure their practices are linked in with the TV Macmillan GP Facilitators who can provide support to GPs in using many tools including Decision Support Tools, Practice Profiles etc Commissioners should commission direct access to one-stop diagnostic to increase capacity & improve quality of endoscopy to reduce unnecessary deaths from colorectal. Commissioners should ensure CA125 and trans-vaginal ultrasound are undertaken concurrently and GPs consider referral along ovarian pathway for suspected ovarian cancer. Commissioners should ensure Primary Care implements safety-netting processes so patients where appropriate are recalled for chest X-rays.

14 Cancer Breast Open Access Follow up Background The cancer survivorship vision recommends that cancer patients should be assessed following initial treatment and then be assigned a level of risk of developing consequences of treatment or further disease. An individual care plan would then be drawn up addressing the whole range of needs an individual might have after treatment with the aim of minimising risks and supporting the patient to manage on-going conditions. * Currently across Thames Valley, 1 Trust is in the pre-planning stage, 2 Trusts are in the implementation stage and 3 have implemented the pathway. Rationale Improved rates for cancer survival/increased life expectancy will require increased capacity for follow up. NHS Improvement piloted risk stratified pathways in breast, colorectal, prostate and lung which provided a national direction for best practice. Model of Care recommendations. No evidence that routine follow-up identifies disease recurrence Patient experience SCN Recommendation Patient initiated follow-ups Commissioners should define and renegotiate contracts with Trusts to include early discharge and rapid re-access for breast cancer patients with a view to introducing similar pathway changes for prostate and colorectal cancers. The target for Re-access to services should initially be set at 90% of all patients seen within 2 weeks *A Model of Care for Cancer Services, 2010

15 Cancer - Survivorship Background The Recovery Package has been developed and tested by the National Cancer Survivorship Initiative (NCSI) (NHS Improvement 2012) to assist people living with a diagnosis of cancer to prepare for the future, identify their individual needs and support rehabilitation to enable people to return to work and or a near normal lifestyle. It has been designed to complement the stratified care pathway (NHS Improvement 2012) which enables individualised follow-up care as a supported self management programme, shared care or complex care. SCN Recommendation Commissioners should ensure the implementation of a Recovery Package as per the National Cancer Survivorship Initiative recommendations. Commissioners should commission psychological support for cancer patients which is currently inadequate for the population of Thames Valley. Recent papers show high risk of depression in cancer which can be better managed. Commissioners should consider work with HWB to commission Lifestyle programmes to promote positive life choices that impact on health. Manage cancer as a LTC

16 Neurology Over 37 million for elective and non-elective admission in 2012/13 in Thames Valley (excluding Milton Keynes) 1.1 millions outpatient attendance to Neurology in 2012/13, OUH actual spend for 13/14 was 5,343,098 for neurology outpatients (New- 2,958,706 and follow up - 2,384,392) Elective Non-Elective 2009/ / / / / / / /13 10,737,984 11,207,984 10,630,915 14,271,982 18,294,918 18,054,912 20,995,706 22,801,349

17 Neurology Background Neurological disorders such as chronic headaches, movement disorders and epilepsy are hugely prevalent, impart major longterm disability and are very costly. There are a lack of designated leads, formalised integrated pathways and informed neurology commissioning. The cost of providing emergency admissions equated to over 22 million in 2012/13 (NCS Report for TVSCN), mostly attributable to headache, epilepsy and movement disorders. Comorbidity data indicated that the main cause for admission for neurological disorders, were potential preventable infective conditions such as urinary tract infection or lobar pneumonia. SCN recommendations Delivery of integrated neurological healthcare Establish a Neurology Strategy Forum to coordinate best practice neurology service designed around patients Development of patient self-management resources Improve first contact with GP and ED staff through a clinical decision support tool Improved triaging of patients seen in secondary/tertiary care to ensure appropriate patient access Establish joint community-gp-hospital neurology teams, coordinated by a community specialist nurse, for the high volume conditions of headache, fits/funny turns and movement disorders Services offered may include: Education/Patient support meeting facilitated by specialist team and run by patient expert(s); Nurse led telephone or physical clinics for all follow up visits; Clinics operated in GP practice by GPwSI and outreach Consultant clinics Rapid Community Intervention URGeNT Urgent Response General Neurology Team to reduce emergency admissions and LoS CCG commissioning intentions There is a coordinated approach to service provision to meet patient needs through establishment of strategic forum An integrated care pathway is established for the major groups of neurological disorders (headache, fits/funny turns, movement disorders, MS, MND, neuromuscular disorders) Neurology patients get rapid referral and assessment of worrying symptoms through clinical decision support tools and referral gateways Expertise for managing neurological disorders is maintained in the community through the establishment of integrated healthcare teams and use of clinical informatics/connected devices Patients with neurological LTC have access to rapid intervention to prevent emergency admissions and/or reduce LoS

18 Heart Failure Heart failure all age admission 2012/13: Thames Valley is better than England average, but there is clearly identified gaps via CVD Commissioning for Value Pack for CCGs which is benchmarked to similar CCGs Proportion of deaths at home from heart failure: lower in Thames Valley Source: CVD Profiles

19 Heart Failure Background Many of the issues highlighted nationally in delivering heart failure services are replicated across Thames Valley. These are: Heart failure accounts for 5% of NHS spend Emergency admission rate for HF has fallen by less than the England average over the reviewed period. There is a higher than average emergency admission rate for deprived areas than the England average. Locally the inconsistencies in service delivery are amplified by governance issues particularly relating to data quality and data transparency. Previous work has been effective in engaging clinical colleagues but there has been limited representation from commissioning representatives. There is not a consistent end to end service model across Thames Valley which can ensure the actions of the Heart Failure group either currently or in the future group become embedded practice at primary care level. As yet no comprehensive work plan has been made available which addresses the gap between good practice and local delivery. SCN Recommendations Ensure rapid access for patients with new symptoms including consultation with an expert (consultant); as for rapid access for patients with chest pain see NICE CG95 quality in care outcomes; Ensure rapid access for decompensation as a 24/7 service to improve outcomes and integrated services; Develop a pathway of care for HF. Consider development of one stop shop for HF to include diagnosis and ambulatory care. Provision of Community Services across the medium/long term for adequate provision of HF nurses (moving towards 1 nurse for 50 patients) so as to ensure community heart services titration, medication review and a communication network that keeps patients out of hospital. QIPP savings being calculated for the region

20 Familial hypercholesterolemia Estimated Prevalent FH and proportion of undiagnosed for CCGs Estimated prevalent FH cases (1 in 500) Proportion of undiagnosed (85%) mid 2012 CCGs population NHS Aylesbury Vale 196, NHS Bracknell and Ascot 132, NHS Chiltern 317, NHS Milton Keynes 257, NHS Newbury and District 105, NHS North & West Reading 99, NHS Oxfordshire 647,085 1,294 1,100 NHS Slough 141, NHS South Reading 107, NHS Windsor, Ascot and Maidenhead 138, NHS Wokingham 156, Thames Valley Strategic Clinical Networks 2,301,349 4,603 3,912 Data source: Mid 2012 population, ONS Estimated prevalence: The prevalence of heterozygous FH in the UK population is estimated to be 1 in 500. Scriver CR et al cited in Neil HA, Hammond T, Huxley R, Matthews DR, Humphries SE. Extent of underdiagnosis of familial hypercholesterolaemia in routine practice: prospective registry study. BMJ. 2000;321:148

21 Familial hypercholesterolemia Background Over 100,000 people have familial hypercholesterolemia (FH), but only 15% are currently identified. Left untreated, 50% of men with FH have coronary heart disease by the age of 50 years and at least 30% of women by the time they are 60 years. Hence, in 2008 NICE recommended a patient pathway to identify and treat people with FH but by in large that pathway is not commissioned. Early identification of FH followed by early intervention with statins effectively reduces premature morbidity and mortality due to cardiovascular disease. The role of familial hypercholesterolemia premature death is well documented. Across Thames Valley review has shown that there are variations in service access and provision of cascade testing to families with the appropriate risk profile Recent evidence confirms that costs are now less than 50% of the original 2008 estimates provided by NICE SCN Recommendations Commissioners should commission a dual care pathway in which primary care manages the majority of the patients in the cascade testing pathway November 2014 British Heart Foundation are setting up a second round of funding (circa k per application to support cascade testing across providers)

22 Diabetic care Variations in Eight Care Processes Data source: National Diabetes Audit 2011/12 and 2012/13 Risk of major amputation among people with diabetes (Patients experiencing the complication at least once in the 2 year period) Data source: CVD profile 2014, NCVIN

23 Diabetic care - DOVE results TV WAM Bracknell Oxford Slough W ham NWR AV Chiltern SR Newbury MK

24 Diabetic care Background Working closely with the Diabetes National Clinical Director (Prof Jonathan Valabjhi) and NHSIQ the CVD SCN have identified a portfolio of interventions to support effective care of patients with diabetes. These include: Supporting all stakeholders in the care pathway to maximise overall uptake of the 8 diabetes care processes through engagement, facilitation and education Reducing variation in uptake of the 8 care processes between providers; Supporting commissioners and providers to deliver excellent foot care for patients with diabetic feet Ensuring that diabetic patients with hypoglycaemia receive an effective approach to subsequent management As a result of this work across the patch, we anticipate improved diabetic care (eg better controlled HbA1C, blood pressure and cholesterol) reduced numbers of major and minor feet amputations, and safer management of patients with hypos with a consistent approach to management in Thames Valley SCN Recommendations Participation and engagement with local leadership groups aiming to drive up quality of diabetes care through the House of Care model. Use of care planning, structured healthcare professional education and structured patient education. This will improve the 8 care processes and minimise variation Examine spend in relation to diabetes to ensure maximum value obtained, include medicine management. Commission a clear documented and effective comprehensive diabetic foot care pathway supported with a multidisciplinary foot team as supported by national clinical lead

25 Acute Kidney Injury Background Acute Kidney Injury (AKI) is an emerging global healthcare issue. It is estimated that one in five emergency admissions into hospital are associated with AKI and that up to 100,000 deaths in secondary care are associated with AKI. The 2009 NCEPOD report Adding Insult to Injury identified that a quarter to a third of all cases could be prevented through earlier diagnosis and improving assessment of risk factors for AKI and acute illness NHS England in partnership with the UK Renal Registry has recently launched a National AKI Prevention Programme which will include the development of tools and interventions to improve the detection and management of patients at risk or with AKI. A priority for the Programme is the development and adoption of e-alert systems which will proactively notify clinicians when a patient has AKI, supporting implementation of AKI NICE guidance (CG169) and the recent Patient Safety Alert: Standardising the early identification of Acute Kidney Injury published on 9 June 2014 SCN Recommendations Identify an AKI champion across locality/unit of planning to raise awareness of AKI through education and training; Implement an e-alert system linked to Trust pathology systems to increase pre-diagnosis rates (information can be found via the National Work programme recommendations) Develop and implement AKI care guidelines and risk assessment tools across primary and secondary care

26 Stroke Services CVD Commissioning for Value Pack for CCGs has highlighted stroke emergency admissions in some CCGs, particular of LOS (6 out of 11 CCGs) CVD Commissioning for Value Pack Stoke Emergency Admissions CCGs High costs High numbers High Lengths of stay NHS Aylesbury CCG NHS Bracknell and Ascot CCG Y Y NHS Chiltern CCG Y Y NHS Milton Keynes NHS North and West Reading CCG Y NHS Newbury and District CCG Y NHS Oxfordshire NHS Slough Y Y NHS South Reading Y Y NHS Windsor, Ascot and Maidenhead NHS Wokingham Y SSNAP Apr June 2014 performance

27 Stroke Services Background Working closely with the Stroke National Clinical Director (Prof Tony Rudd) and NHSIQ the CVD SCN identified a portfolio of interventions intended to : Reduce the incidence of stroke; Support the most effective immediate treatment of stroke Minimise the longer term clinical consequences of stroke; and Promote the most effective recovery possible Reduce morbidity and mortality through adoption of the London model of stroke care As a result of this work across the patch, we would anticipate fewer strokes, reduced length of stay in a stroke unit, reduced acute presentations to A&E SCN Recommendations Ensuring that primary care /general practice work to identify and optimise medication to the maximum extent possible to lessen the number of preventable strokes in the wider population (utilising GRASP suite of tools) To ensure that all patients with Stroke are treated initially in a HASU - recent evidence shows improved outcomes in morbidity and mortality occurs when patients are treated in a stroke unit (treating 600 or more patients) in the early phase of treatment All patients with stroke to receive IPC sleeves during their treatment promoting recovery as evidenced by the CLOTS 3 trial Promote the use of Early Supported Discharge Maximise 6 week and 6 month reviews to assess patient progress as part of care planning as per Stroke guidelines

28 ?30 0 Distance / Driving Time 600 Horton OUH 23 miles / 38 min Wexham Park Wycombe 14 miles / 22 min Milton Keynes Bedford 18 miles / 29 min

29 Another way? HASUs 7 Acute / Rehab Stroke Units

30 End of Life Care Proportion of death in usual place particularly low in NHS Milton Keynes and Slough 2011 and 2012 VOICES surveys

31 End of Life Care Background Care of the dying is a litmus test for the NHS and challenges us to respond with the best the profession has to offer in terms of clinical expertise, considered professionalism, personalised care and human compassion Effective commissioning of end of life care leads system change which is sustainable and in which patients and populations are supported and have access to most appropriate cost effective services to meet their needs Early identification of those entering last months of life, advanced care planning and effective communication can lead to reducing avoidable admissions and patients receiving care in their preferred place. However we know from the results of the national VOICES survey and also End of Life (EoL) Care Profiles that there is significant variation between CCGs across Thames Valley in terms of patient and carer experience and achieving death at home. SCN recommends that Providers must be working towards achieving the 5 Priorities of Care as outlined in the Report One Chance to Get it Right and embedding the 34 recommendations to ensure that Care of the Dying is everyone s business Recommendations A co-ordinated approach to service provision for patients approaching EoL including Electronic Registers. CCG intentions are linked to those of their HWB to allow integrated and seamless care Health Professionals are supported to identify, as early as possible, patients approaching end of life and to communicate effectively with patients and relatives They are assured that Providers have a high level of commitment to end of life care, governance and education by embedding the 5 priorities and 34 recommendations in the report One chance to Get it Right They regularly analyse their performance via data available i.e. EOL Care Profiles and VOICES Survey particularly with a view to identifying and addressing unwanted variation, and perform annual Practice level audits on patient and carer experience at end of life They engage with EOL Locality Groups and TV Networks to share best practice and promote integrated care across relevant stakeholder groups and also strongly consider the TVSCN offer of Project Support to map end of life provision in their locality and identify actions needed to embed the recommendations of One chance to get it right Consider funding paediatric palliative care

32 Long Term Conditions 1) Reported having a care plan 2) Use their written care plan to manage their day to day health Source: LTC Dashboard, as at August 2014

33 Long Term Conditions Background The burden of disease regarding LTCs is well understood with 70% of the health budget focussed in this area of care. Evidence supports the premise that the majority of people with LTCs want to be more informed and in control of their care. There is also evidence that a significant proportion of people with LTC suffer from mental health problems (particularly depression), and that this group use 60% more physical health services than those with LTC but without mental health problems. Person centred care/personalised care/proactive care/ supportive self-management are a common recurring theme in many key policy initiatives- better care fund, integrated care, transforming primary care etc. CCGs aspire to deliver this approach to care, and this should be at the core of local strategies and visions for the future of health services for the local population and in all new models of care To make this a reality and realise the full benefits for patients and the system, CCGs need to recognise the importance of all the complementary elements that need to be addressed as encompassed in the House of Care framework The SCN is providing a suite of resources to support CCGs in achieving this transformational change, however the SCN cannot do this in isolation. CCGs need to commit to the commissioning aspects of the framework- education of patients and health professionals, on-going support to ensure embedding at practice level and to place person centred care as a core element to care. Recommendation Use the House of Care framework as common approach for all service redesign and out of hospital/primary care strategies. Provide nationally recognised patient education programmes for people with LTCs eg DAFNE, DESMOND, Expert patient, to be delivered in a range of ways to reflect the needs of the local population. Provide access to psychological therapies as part of an integrated LTC model of care Develop and commission new models of care that recognise co-morbidity including frailty Engage with the SCN offering to support adoption the House of Care and of care planning, including specifically investing in trainers to support implementation at practice level, Require health professionals to attend training and education to enable them to work in partnership with patients. Mandate the adoption of patient centred care planning for patients across all LTCs, require all providers to adopt this approach.

34 Dementia - Diagnosis National target of 67% dementia diagnosis against estimated prevalence has not yet been met anywhere in Thames Valley

35 Dementia Background The Prime Minister s Challenge on Dementia set out a national commitment to diagnose of two thirds of estimated prevalence by March This was coupled with the required provision of memory clinic services within each CCG. There are approximately 600,000 people estimated to have dementia in England. Over 50% have been diagnosed and a further 15% more is needed to reach the national ambition. This is equal to 90k more patients. Dementia rarely occurs in isolation. Around 80% of dementia patients have other long term conditions. This makes diagnosis of dementia for all patients an important part of wider health and social care. People with dementia admitted to hospital are likely to have a length of stay four times longer than normal. Evidence suggests that dementia patients with a care plan will have fewer admissions and shorter length of stay. Equally, the carers of people with dementia have less stress and better experiences of care. 80% of people in care homes have dementia and yet the diagnosis rate is less than the 50% average. New National Enhanced Service (NES) for Dementia Identification launched in October 2014, in addition to existing Dementia DES and any locally existing LES Beyond April 2015, diagnosis rates should remain at or above 67% and memory clinic wait times below 40 days SCN Recommendations Utilise the Dementia Diagnosis 10 Step Tool Kit Focus on correctly adding primary care read codes for dementia Care home case finding Target secondary care vascular patients and identify those at high risk Ensure post diagnostic signposting to services and provide services levels to meet demand two thirds of estimated prevalence as a minimum All memory services should aim to see appropriate referrals within 4-6 weeks and for no one to wait longer than 12 weeks from referral to diagnosis