Appendix 1 Mr Dwight McKenzie Scrutiny Review Officer Legal and Democratic Services Ealing Council Perceval House 14 16 Uxbridge Road Ealing London W5 2HL Cognitive Impairment and Dementia Service Elm Lodge 4a Marley Close Greenford Middlesex UB6 9UG Tel: 020 8483 2647 Fax: 020-8483 2654 email: wlm-tr.opscmhtwest@nhs.net Response to Question 1: An update on any mapping and identification of existing dementia services and their costs including general and acute psychiatric care, primary care, nursing and residential care. West London Mental Health NHS Trust has a dedicated service for Cognitive Impairment and Dementia which incorporates both assessment and management of all aspects of Dementia care. In Ealing the dedicated service is based in two different centres, Elm Lodge in Greenford which covers the west of the borough and Sycamore Lodge in Acton which covers the East of the borough. Both of these centres have a Consultant Psychiatrist, Doctors, Nurses, Occupational Therapists and Psychologists, a Multi Disciplinary Team. There has been a significant increase in the referrals for assessment of dementia across the borough and we accepted 812 referrals in 11 months ( November 2012 to September 2013 ) approximately equating to 885 accepted referrals a calendar year. We also used to run a dedicated service for Working Age Dementia (people under the age of 65) which has now been incorporated into our ageless service to ensure equal access to resources for people of all ages. The number of referrals for this relatively younger patient group is significantly higher that the national and local assumptions and currently runs at approximately 60 cases per year, this needs further exploration. Our referrals are mostly received from Primary Care but also other agencies including Social Services, Acute General Hospitals can make referrals. All referrals are screened and there is an inclusive approach towards the acceptance of referrals. Each referral is assessed in detail following a comprehensive template by a trained member of the Multi Disciplinary Team. The assessment is supplemented by investigations as appropriate including blood tests, ECG and an MRI brain scan and neuropsychological assessment as per the guidelines from the National Institute of Clinical Excellence (NICE Clinical Guideline 42 ). Following completion of the assessment a diagnosis is given to the patient and the carer and the implication of the diagnosis, prognosis and treatment options are discussed along with signposting to other resources and various detailed discussions about the needs of the patient and the carer and follow up counselling is offered whenever possible. The patients who commence on medication remain under our care and this includes medication prescribing. We are currently working with Primary Care and the Clinical Commissioning Group to explore options of transferring the prescribing of clinically stable patients who are on anti-dementia medications and uncomplicated dementias to Primary Care. This will significantly free up specialist resources which can be then clinically redirected to speed up
the diagnostic process and to reconfigure existing resources to input into supporting people with more advanced stages of the disease often with challenging or difficult behaviour in the community. This has now been agreed in our CQUIN ( Care Quality and Innovation ) Target for 2013-2014 & 2014-2015. The cost of prescribing of memory treatment was 283K for the year 2012-13 and it is a significant proportion of non pay costs. We are working with CCG Dementia lead to shift the prescribing to primary care where suitable and hope to begin the process by the end of this year ( 2013 ). One goal of the service remains to try and reduce in-patient admission and institutionalisation and supporting people s independence but at the same time managing risk responsibly. We have regular input to support people in Nursing/ Residential care and more recently identified nurses to have regular input in larger Care Homes to maintain continuity. These are trained mental health nursing staff from Cognitive Impairment & Dementia Service for all grades of seniority. Our Consultants are also involved in Integrated Care Pathway Multi Disciplinary Groups and are regularly engaging with GP s and other Multi Disciplinary professionals to focus on managing older patients with complex mental and physical health needs in the community with a view to reduce admission to a general hospital and attendance in the accident and emergency department. This approach has been highly valued by all the partners of the Multi Disciplinary Group and has been a national pilot for the last three years. This project has commanded several national prizes including the coveted award by health service journal for managing long term conditions and there is key focus on elderly people and dementia. Our Care Pathway is still evolving and I embed a current version (Figure 1, see below). The estimated cost for Ealing Cognitive Impairment and Dementia Service from the Trust is 3.6 million for the year 2012/2013. This incorporates both pay and non-pay costs. We have agreed with commissioners to undertake a 3 borough ( Ealing, Hounslow and H & F ) service specification exercise. This will involve the definition of a pathway and should involve the costing of that. Response to Question 2: The role and contribution of individual services to the overall system of care for those with dementia in terms of commissioning objective cost and benefits. West London Mental Health NHS Trust plays a key role in providing the specialist service for dementia assessment, diagnosis, management, on-going management, emergency management and in-patient care. It also runs The Limes which is the continuing care service for the most difficult to manage patients in the community. West London Mental Health NHS Trust is one of the very few Trusts nationally who have a dedicated Cognitive Impairment and Dementia Service. Our service model is based on the National Institute of Clinical Excellence Guidelines and we provide a comprehensive and time efficient assessment service incorporating advanced neuro-imaging to give a robust diagnosis of dementia. Our approach is holistic and patient and carer centred. We believe our role is unique because we are able to provide specialist healthcare input in this group of patients in all stages of their illness. Response to Question 3: dementia care. Insight into any performance management system for We follow the NICE Guidelines with a robust system of reviewing patients that includes not only a review of their cognitive functions but also their behavioural and psychological problems and functional abilities. Our treatment of dementia care has been internally audited and is NICE compliant. We have participated rigorously in the POMH UK (Prescription observatory for Mental Health UK, an initiative by The Royal College of Psychiatrists )
National Audit on the use of anti-psychotic medication in dementia and in the year 2012/13 we have submitted the maximum number of case records nationally amongst 54 participating Trusts. Our response rate was 50% higher than the next comparable Trust. In the National Survey it was observed that we have one of the lowest usages of anti-psychotic medication for this group of patients ( 4 % across our trust compared to 13% nationally). This could be considered a key quality indicator for the care of people with Dementia because there has been so much concern raised with regard to inappropriate use of this medication in this patient group. However, the audit also highlighted that there is room for improvement in our monitoring of patients who are on this medication which we are addressing. We have developed a protocol to help primary care physicians to manage Dementia patients who are on antipsychotic medication and this is due to be adopted. The draft version has been submitted and we are expecting a meeting soon with commissioners to take this forward. We are also currently preparing to apply for the Royal College of Psychiatrist accreditation for our memory service and that would incorporate an audit of local GPs satisfaction about our service. We also have monthly performance meetings which check our compliance with KPIs (Key performance Indicators). We are planning to introduce an electronic system for feedback from patients and carers (the carers one is one of our CQUINS ). From a wider perspective one key national priority is to improve the rate of diagnosis of Dementia. In Ealing it is approximately 50% (Source: Alzheimer s Society : England mapping the Dementia Gap 2011 & 2012 update ) and a key target is to improve the rate to 60% by 2015/16 locally. One key issue in this context is identification of potential patients and referral to specialist services. From the specialist service point of view one key target would be a robust assessment delivering a time efficient diagnosis. The other key area of focus would be rapid response in the community in times of crisis and avoidance of inpatient admission. The proportion of people with Dementia living in the community and an overall reduction of placement in care home would also indicate good care in the community and carer support. There has to be focus on support following the diagnosis, living well with dementia. Response to Question 4: Insight into any developed or developing Joint Strategic Needs Assessment ((JSNA) on dementia. Dr Will Maimaris, Specialist Registrar in Public Health, London Borough of Ealing completed an excellent JSNA on dementia in Ealing earlier this year and I would highly recommend its content. He observes: Ealing has some strong local services for people with dementia, which are valued by services users and other stakeholders. These services include the Memory Clinic (part of the Cognitive Impairment and Dementia Service), Ealing Hospital s Liaison Psychiatry Team and the services provided by Dementia Concern Ealing and the Alzheimer s Society. However, the areas of need that are identified in the report from our perspective are: - Intermediate care and community services require specialist dementia input in order to support people in their own homes and prevent hospital admissions. - End of life care planning is often not discussed during the early stages of dementia. - For the care of people with learning disabilities and dementia improved linkages are required between specialist dementia services and learning disability services.
We are working with ICE service in Ealing and our commissioners to increase our specialist input to intermediate care and Clayponds hospital (via liaison service). We would continue to focus on these objectives. Response to question 5: Any identified shared risk, and assessment of a Service s contribution to managing risk of escalation to intensive forms of support for dementia care; i.e. residential, and inpatient care One key area of our service is managing crisis situation in the community and our key partners are CRHT ( Crisis resolution & Home Treatment Team run by WLMHT ), primary care, social service, intermediate care service ( ICE ) and other community services. Management of emergency in the community in the context of Cognitive Impairment & Dementia are often very complex and clinically challenging. For example a behavioural disturbance could often be a manifestation of an underlying physical problem in a frail individual who may be refusing engagement. We also have to deliver the care within statutory framework of mental capacity and right of self determination vs. risk, need and duty of care. The key approach for good management and risk sharing is proactive approach across professional and organisational boundaries and good communication. There are both good and not so good examples. From our perspective our presence in the intermediate care medical team would enhance care. The current approach is to ensure that care is provided in the community wherever possible in line with NICE guidance which highlights the need to avoid acute admissions wherever possible due to the additional disorientation and distress this can cause for this particular patient group. Available inpatient beds have been reducing over time. This needs to be coupled with a more rigorous approach of managing people in the community or in settings of less intensity (e.g. care homes instead of inpatient psychiatric unit) and use of detention under MHA only as a last resort. This is improving but much more work needs to be done between organisations, particularly between our service and Ealing Social Service to bring approaches to an agreed rational alignment. Response to Questions 6: Update and insight into any commissioning programme proposed and or agreed which achieves best outcomes and meet efficiency targets Question 7 Progress and performance in delivering targets against any existing Commissioning plan We have been working jointly with our commissioners and other stakeholders in a programme board to shape commissioning intentions for this and coming year. The key considerations are quality, productivity, patient and carer focus and cost effectiveness. We have in addition agreed to carry out a piece of work jointly with commissioners that define a clear service specification to be achieved by the end of the financial year. We have seen a significant increase in new referrals over the last 2-3 years and also a trend of people referred in an earlier stage of illness who need very careful assessment to avoid incorrect diagnosis. This early intervention approach has been the direct result of our involvement in the integrated care pilot for frail elderly, as well as working with commissioners on a specific target for increased identification of dementia. Further work is going on this year also to focus on a shared care approach in partnership with primary care on the management of those with dementia who are stable.. This latter piece of work is incorporated into our CQUIN targets agreed with our commissioners for 2013-14. Also incorporated into our CQUIN is that of reducing the use of antipsychotic medication (in line with the national focus in Dementia) and managing them well, and carer and user satisfaction.
Picture 1 (Diagnostic Care Pathway)