NHS HOUNSLOW CCG GOVERNING BODY Date: 15 th May 2013

NHS HOUNSLOW CCG GOVERNING BODY Date: 15 th May 2013 Report title Dementia Services in Hounslow This report aims to give the CCG Board: an overview of national policy and direction of travel for dementia services; an overview of current provision of dementia services in Hounslow; update on the dementia action plan; the current position of dementia prevalence and diagnosis targets for Hounslow; and highlight the gaps in provision and the CCG commissioning intentions in addressing these gaps and the rising demand in Dementia. Executive Summary and Rationale The report also requests the CCG Board to agree: to fund a year pilot for the function of a dementia advisor from the Alzheimer s Society; to promote the National Dementia GP contract across GP practices in Hounslow; and to work with Ealing and H&F CCG to develop a single specification for Dementia secondary care, primary delivered by WLMHT. Author Clinical Lead Manager Lead Presented by The Governing Body is asked to: While this report focuses on the health commissioning responsibilities the CCG acknowledge that the Local Authority are a key stakeholder in ensuring the continued development of dementia services and implementation of the dementia action plan. Sunny Mehmi Senior Joint Commissioning Manager: Mental Health NWL Commissioning Support Unit (Hounslow) Dr Kultar Garcha CCG GP Dementia Lead Mary Crawford Assistant Director /Head of Joint Commissioning NWL Commissioning Support Unit (Hounslow) Sunny Mehmi Senior Joint Commissioning Manager: Mental Health NWL Commissioning Support Unit (Hounslow) Mary Crawford Assistant Director /Head of Joint Commissioning NWL Commissioning Support Unit (Hounslow) Note the: - current position of dementia prevalence and diagnosis target for Hounslow; - the CCG commissioning intentions to address the rising demand in Dementia; - the gaps in dementia provision and pressures across the system; - the update of the dementia action plan; Agree to: o the funding of a year pilot for the function of a dementia advisor from the Alzheimer s Society at a cost of 40,000; Page 1 of 23

o o promote the National Dementia GP contract across Hounslow GP practices which will facilitate timely diagnosis and support for people with dementia; and agree to work with Ealing and H&F CCG to develop a single specification for Dementia secondary care. Purpose and scope of report Overview - CCG Responsibilities It is the responsibility of the CCG to know and understand the prevalence figures for their population in order to deliver key services e.g. memory assessment and related support and propose investment scenarios based on prevalence. Work with local partners, in particular, the Local Authority in delivery of key services. All CCGs are required to appoint a clinical lead for overseeing the delivery of dementia services and deliver a dementia action plan to improve provision in their localities. Hounslow current needs assessment (map and trajectory) Hounslow GPs have 251,623 patients on their practice lists. 11% of these are aged 65 and over. This is lower than the England average of 16% Based on the national dementia register, the prevalence rate of dementia patients in Hounslow should be 1,829. However, Hounslow has 868 patients on the GP dementia register, this is at rate of 47.5%, in line with national average. The dementia diagnosis rates of GP Practices varies significantly, with some GP practices with rates as low of 6% Dementia diagnosis rates trajectory target Hounslow CCG have submitted a trajectory target to DH of 65% by 2015, which mean a target population of 1,294 on the GP dementia register. Number of patients registered with dementia % on GP Dementia register based on prevalence 2011 2012 2013 2014 2015 868 970 1,075 1,183 1,294 47.5% 51.8% 56.2% 60.6% 65% Hounslow CCG & LB Hounslow Dementia Commission Intentions While there is no significant new investment funds into Dementia Services in 2013/14, Hounslow CCG will focus on: 1. developing a provision which promotes advice and information on services and activities for people with dementia and their carers 2. working with WLMHT to support an increase in resourcing for secondary care dementia service to enable them to meet the increase in demand 3. reviewing the use of all psychotropic drugs including antipsychotic drugs for people with dementia across primary and secondary care and develop a strategy to reduce inappropriate use 4. promoting the access of the Council s Floating Support and Supporting Independence Services to people with dementia and their carers, allowing patients to stay at home as long as possible 5. work with WLMHT to identify carers and are referred to services for respite, information and support services Page 2 of 23

Purpose and scope of report 6. delivering an information awareness campaign that raises the awareness of the importance of Co- Ordinate my Care i.e. EOL care planning amongst GPs for people with dementia when required Progress of Dementia Action Plan The Dementia Steering Group, chaired by the CCG GP Dementia lead is responsible for monitoring and ensuring the continued progress of the dementia action plan. The update on the action plan can be seen in Appendix 1. Generally, the actions are on track to be delivered with the exception of action within the priority area Mental Health Promotion and Prevention. As part of this report the CCG Board are asked to commission a Dementia Advisor (see main report for full details) to process this work. Next Steps Commission a Dementia Adviser Service The Board are asked to agree funding of 40,000, (of which, the funds have been identified within the existing Mental Health budget) to pilot a Dementia Adviser service from the Alzheimer s Society. The new service will provide personalised information, advice and signposting services to people in the process of getting a diagnosis or from diagnosis of dementia onwards. The Dementia Adviser will signpost and facilitate access to other services in Hounslow (such as Peer support groups and/or a referral to a Dementia Support worker, as appropriate to the needs of the person with dementia) and will link closely with the Care Navigators model. See Appendix 2 for Dementia Advisor Service outline. National Dementia GP contract Promote across Hounslow GP Practices The Board are asked to agree to promote the rollout of the National Dementia GP contract across GP practices in Hounslow. Following changes to the GP contract for 2013/14, the Secretary of State for Health has directed the NHS England to establish an enhanced service to provide timely diagnosis and support for patients known to be at risk of dementia. GPs will be paid to identify patients at risk of dementia and make an 'opportunistic offer' to assess them during a routine consultation. The list of at-risk patients includes all patients over 60 with cardiovascular disease or diabetes, as well as patients with learning difficulties or neurological conditions. GPs should then refer patients to memory clinics when dementia is suspected and offer treatment for memory loss. They will also need to offer health checks to carers of people with dementia. See Appendix 3 for National Dementia GP contract and payment outline. GP Locality meetings Some GP practices with low dementia diagnostic rates may be a result of not recording the diagnosis correctly on the system. Therefore, we will attend future Locality Meetings to highlight this with all GP practices and target those ones that have a particularly poor diagnosis rate compared to their prevalence. Links with other CCGs Through the Joint Commissioning Team at NWL CSU Hounslow CCG are working with Dementia commissioning leads in Ealing and Hammersmith and Fulham to ensure a consistent message and approach to reviewing WLMHT secondary care dementia services. Along with the three CCG GP Dementia leads the aim will to develop one shared specification with separate schedules for the three boroughs and an approach to the methodology including clear statement that we wish/need full engagement of WLMHT in process. This process has been agreed at the WLMHT Transformation Board. Page 3 of 23

Purpose and scope of report Dementia CQUIN (still in development) As part of the 2013/14 contract arrangements, WLMHT will be expected to deliver on the dementia CQUIN, which has 4 elements: Indicator 5a WLMHT to send GP practices full and complete registers of all patients with a diagnosis of dementia under the Trust's care on a quarterly basis. Indicator 5b - Building on the 2012/13 CQUIN investment, WLMHT to provide evidence of the implementation of the quality improvement plan to reduce inappropriate antipsychotic prescribing to people with dementia, with particular focus on providing an evidence based training programme across the full commissioner catchment area. Indicator 5c - Audit of antipsychotic reviews and evidence of a reduction in antipsychotic prescribing through the implementation of the action plan from 2012/13 POMH-UK audit results. Indicator 5d - Deliver a carers training programme, making better use of local investment in supporting carers training and with particular focus on social inclusion, carers of newly diagnosed dementia patients and access for those from under-represented groups. Links to CCG strategy and objectives This report supports the Hounslow CCG Out of Hospital Strategy Care closer to home and the CCG Dementia Action Plan. Supporting documents Links to websites: National Dementia Strategy http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_094058 Dementia DES http://www.england.nhs.uk/wp-content/uploads/2013/03/ess-dementia.pdf Hounslow Joint Commissioning Older People s Strategy 2011-16 http://www.hounslow.gov.uk/older_peoples_mental_health_strategy2011-16pdf.pdf Hounslow CCG Dementia Action Plan http://www.northwestlondon.nhs.uk/_uploads/~filestore/6f4725dd-5201-46cd-b1d1- E27229D03704/hounslow-ccg-dementia-action-plan-september-2012.pdf. Financial and resource implications Request to authorisation one year pilot of a Dementia Adviser Service from the Alzheimer s Society at a cost of 40,000 from within the MH Budget. Quality and Performance implications Page 4 of 23

Purpose and scope of report The report aims to improve the performance across NHS Outcome Framework: Domain 2: Enhancing quality of life for people with long-term conditions Domain 4: Ensuring people have a positive experience of care Stakeholder involvement and public engagement The Dementia Steering group consists of active members of WLMHT, LB Hounslow, West Middlesex University Hospital, Alzheimer s Society and a Carer representative have assisted in the developments of the commissioning intentions and identify gaps within the system. Equality impact analysis None has been taken Legal Issues No legal issues at present Key Issues and Risks Key issue concerns the increase in people with dementia and the ability of community, primary and secondary care to support those people and their carers. Governance (Audit Trail) and reporting None Recommended Actions; Communication Plan; Next steps - Agree to the funding of a year pilot for the function of a dementia advisor from the Alzheimer s Society at a cost of 40,000. - Agree to promote the Dementia DES across Hounslow GP practices which will facilitate timely diagnosis and support for people with dementia - Agree to work with Ealing and H&F CCG to develop a single specification for Dementia secondary care - CCG Board to be updated on progress, concerns and risk in six months. Page 5 of 23

Report: Dementia Services in Hounslow Overview - CCG Responsibilities It is the responsibility of the CCG to know and understand the prevalence figures for their area in order to deliver key services e.g. memory assessment and related support and propose investment scenarios based on prevalence. This report aims to give the CCG Board: an overview of national policy and direction of travel for dementia services; an overview of current provision of dementia services in Hounslow; update on the dementia action plan; the current position of dementia prevalence and diagnosis targets for Hounslow; and highlight the gaps in provision and the CCG commissioning intentions in addressing these gaps and the rising demand in Dementia. Brief description of the Dementia syndrome There is various types of dementia s, and is a collection of symptoms that indicate a syndrome due to illness of the brain, which is chronic and progressive in nature. The conditions that cause dementia will produce changes in a person s cognitive function, personality and behaviour. People with dementia commonly experience problems with memory and the skills needed to carry out everyday activities. Dementia is not part of normal ageing. Although it can occur at any age, it s more common in older people. People with LD can often develop dementia as young as 30 years of age. People with dementia often present with complaints of forgetfulness or feeling depressed. Other common symptoms include deterioration in emotional control, social behaviour or motivation. People with dementia may be totally unaware of these changes and may not seek help. Sometimes the family seek care on their behalf. Family members may notice memory problems, change in personality or behaviour, confusion, wandering or incontinence. However some people with dementia and their carers may deny or minimize the severity of memory loss and associated problems. There are growing numbers of people locally who live alone and may not have family members living close by who could support them. Alzheimer s Disease is one of a number of different organic dementia illnesses and are distinct from functional mental health problems that are treatable. They may however be co-morbid with these. Dementia will generally mean a decline in intellectual functioning and usually interferes with activities of daily living, such as washing, dressing, eating, personal hygiene and toilet activities. Pharmaceutical organisations have developed acetyl cholinesterase medications to slow the progress of the illness for some patients with Alzheimer s disease, and research is continuing. National Strategic Context National Dementia Strategy Living Well with Dementia: A National Dementia Strategy 1 was published by the Department of Health in February 2009. The five-year strategy envisaged improvements to dementia services and in 2010 further guidance was issued, which distilled the requirements of the strategy into four main priority areas: 1. Good-quality early diagnosis and intervention for all 1 http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_094058 Page 6 of 23

2. Improved quality of care in general hospitals 3. Living well with dementia in care homes and 4. Reduced use of antipsychotic medication Dementia challenge In addition to the National Strategy, the dementia challenge was launched in March 2012 by Prime Minister David Cameron. The challenge is an ambitious programme of work designed to make a real difference to the lives of people with dementia and their families and carers. The Prime Minister s challenge on dementia (2012) sets out 5 commitments with relevance to CCGs: 1. Increased diagnosis rates through regular checks for over 65s 2. Financial rewards for hospitals offering quality dementia care from April 2012 through dementia CQuIN 3. An innovation challenge prize of 1m for innovative ideas for transforming dementia care 4. A dementia care and support compact signed by care home and home care providers setting out their commitment to deliver high quality relationship based care and support for people with dementia 5. Promoting local information on dementia services National Dementia GP contract To support the increase in diagnosis rate across primary care, DH have instructed NHS England to develop a National Dementia GP contract which will facilitate timely diagnosis and support for people with dementia. 2 This enhanced service will reward GP practices for undertaking a proactive approach to the timely assessment of patients who may be at risk of dementia. The aims of this enhanced service in 2013/14 are to encourage GP practices to: a) identify patients at clinical risk of dementia; b) offer an assessment to detect for possible signs of dementia in those at risk; c) offer a referral for diagnosis where dementia is suspected; and, d) support the health and wellbeing of carers for patients diagnosed with dementia. See specification in Appendix 3. Local Strategic Context Joint Commissioning Older People s Mental Health strategy 3 Hounslow CCG in partnership with Hounslow Local Authority are committed to improving the services and outcomes for people with dementia. In 2011, NHS Hounslow and the London Borough of Hounslow published its Joint Commissioning Older People s Mental Health Strategy 2011-16 for people registered with a Hounslow s GP. The strategy was informed by national policies such as the National Dementia Strategy and the Equality Act 2010 which aims to promote equity of provision for older people. The strategy was developed though consultation with older people, their families and carers and local professionals. They told us what they think our local priorities should be and how best we might address them. The Older People s Mental Health strategy outlined five strategic aims which this action plan is shaped on: 2 http://www.england.nhs.uk/wp-content/uploads/2013/03/ess-dementia.pdf 3 http://www.hounslow.gov.uk/older_peoples_mental_health_strategy2011-16pdf.pdf Page 7 of 23

1. Mental Health Promotion and Prevention: To promote positive mental health and to prevent or delay the decline of a person s mental health throughout their later life and in every care setting; 2. Early Intervention and Assessment: To increase early intervention and the capacity to offer an expert assessment of mental health problems at every stage; 3. Treatment: To develop more efficient treatment pathways for cognitive and functional mental health problems, thereby increasing capacity and the ability to outreach to older people in community settings so that care is as local as possible; 4. Care and Support: To increase independent and supported living options for older people with mental health problems, and reduce reliance on bed based and residential care; 5. Ensuring Quality for Older People: To improve the quality of care and ensure that the right mental health support is available at every stage of a person s journey Dementia Action Plan 4 The Hounslow CCG Dementia action plan published in September 2012 outlined the requirement of how each area intended to progress the objectives within the National Dementia Strategy. The Dementia Steering Group, chaired by the CCG GP Dementia lead is responsible for monitoring and ensuring the continued progress of the dementia action plan. The action plan, aligned with Older People s Mental Health strategy five strategic aims took into account the NICE quality standards for dementia, the Department of Health s The National Strategy Living Well with Dementia (NDS) and the NHS Operating Framework 2012/13 which sets out clear objectives for dementia care. The update on the action plan can be seen in Appendix 1. Majority of the actions are on track to be delivered with the exception of action within the priority area Mental Health Promotion and Prevention. Therefore to progress that element of the action plan and in line with the commissioning intentions the CCG Board are asked to commission a Dementia Advisor. Hounslow current needs assessment (map and trajectory) Hounslow GPs have 251,623 patients on their practice lists. 11% of these are aged 65 and over. This is lower than the England average of 16% Based on the national dementia register, the prevalence rate of dementia patients in Hounslow should be 1,829. However, Hounslow has 868 patients on the GP dementia register, this is at rate of 47.5%, in line with national average. The dementia diagnosis rates of GP Practices varies significantly, with some GP practices with rates as low of 6% (see graph below) 4 http://www.northwestlondon.nhs.uk/_uploads/~filestore/6f4725dd-5201-46cd-b1d1-e27229d03704/hounslow-ccg-dementia-actionplan-september-2012.pdf. Page 8 of 23

Dementia Rates 160% 140% 120% 100% 80% 60% 40% 20% 0% Hounslow GP Practices The national dementia register estimates the following severities of dementia in Hounslow: The national dementia register estimates the following severities of dementia in Hounslow: Mild 1,007 Moderate 597 Severe 225 Total 1,829 Based on ONS population projections, the forecast is expected to increase from 1,829 in 2011 to 1,991 by 2015 (see table below). Prevalence dementia of 2011 2012 2013 2014 2015 1,829 1,870 1,912 1,951 1,991 Dementia diagnosis rates trajectory target Hounslow CCG have submitted a trajectory target to DH of 65% by 2015, which mean a target population of 1,294 on the GP dementia register. Number of patients registered with dementia % on GP Dementia register based on prevalence 2011 2012 2013 2014 2015 868 970 1,075 1,183 1,294 47.5% 51.8% 56.2% 60.6% 65% Page 9 of 23

Stocktake of services what we have currently Dementia services in Hounslow are provided by West London Mental Health NHS Trust (WLMHT), the LB of Hounslow and the voluntary sector. WLMHT are establishing a Cognitive Impairment / Dementia Service. The service will benefit from a single point of access to a single team, ageless service to all those of working age and over, embraces the recovery model and ensures close liaising with Primary care, IAPT recovery teams, local authorities social services, inpatients and partner services. The service is due to be relocated to the Lakeside site at West Middlesex University Hospital in the Summer 2013. There is a Shared Care Protocol between the WLMHT Cognitive Behaviour service and Primary Care In addition, WLMHT together with Imperial College London, have developed the West London Cognitive Disorders Treatment and Research Unit, now designated a Centre of Excellence. Over this time, more than 100 patients have been involved in cutting edge clinical research. LBH have undertake developments of Older People s Resource Centres in Chiswick and a 54 bedded extra care housing facility in Brentford, which includes greater provision for people with dementia. Work is in the final stages of the re-development of Sandbanks into an Older People s Resource centre with a 60 bedded home and day centre. North West London (NWL) cluster piloted an enhanced Psychiatric Liaison service at the WMUH. One of the benefits of the team has been increased and more timely access to psychiatric expertise to old people presenting to Urgent Care Centre (UCC), A&E and or admitted to the wards NHS Hounslow has commissioned as a pilot a multi-agency and multi-disciplinary Integrated Care Team that is helping older vulnerable people remain at home, including those with dementia or be discharged earlier than was the case in the past, the NHS monies for social care (section 256) has been used to support the social care aspects of this team to advoid admission. Hounslow has a Dementia Steering group, chaired by the lead GP for Dementia. The Group consists of representatives from WLMHT, London Borough of Hounslow (social care and commissioning), Alzheimer s society, West Middlesex University Hospital and a carer representative. LBH have tendered Carers Support which will include Outreach support for people with Long Term Conditions including dementia. The Cognitive Behaviour service also runs a Carers Focus group to support carers of people with dementia. Voluntary sector partners, Alzheimers Society, Crossroads and others continue to develop user led services; promote the use of information, advice and advocacy and provide opportunities to increase their knowledge and confidence to help older people and carers to manage their mental health. AgeUK is also present in Hounslow, however do not provide a specific provision for people with dementia. They have recently been commissioned to provide a Befriending service and we are in discussions with them to support people with dementia. Page 10 of 23

Hounslow Dementia Pathway Issues The Cognitive Behaviour Service is at full capacity and the targets for assessment and diagnosis set within the current contract which is being reviewed, alongside a general review. Any significant increase in referrals requires additional resource, either in efficiencies or in revenue terms, to process these, undertake assessments and ensure a timely diagnosis. If there is to be no further investment in services to provide support post diagnosis, this could hold the rate of referrals at a lower level. Hounslow Dementia Commissioning Intentions While there is no significant new investment funds into Dementia Services Hounslow CCG will need to focus on: developing a provision which promotes advice and information on services and activities for people with dementia and their carers working with WLMHT to support an increase in resourcing for secondary care dementia service to enable them to meet the increase in demand reviewing the use of all psychotropic drugs including antipsychotic drugs for people with dementia across primary and secondary care and develop a strategy to reduce inappropriate use promoting the access of the Council s Floating Support and Supporting Independence Services to people with dementia and their carers, allowing patients to stay at home as long as possible work with WLMHT to identify carers and are referred to services for respite, information and support services delivering an information awareness campaign that raises the awareness of the importance of Co- Ordinate my Care i.e. EOL care planning amongst GPs for people with dementia when required Page 11 of 23

Next Steps Dementia Adviser Service The Board are asked to agree funding of 40,000, which, as been identified with the existing Mental Health budget, to pilot a Dementia Adviser service from the Alzheimer s Society. The new service will provide personalised information, advice and signposting services to people in the process of getting a diagnosis or from diagnosis of dementia onwards. Dementia Adviser and volunteers recruited as part of the service will provide accurate, accessible information to help people with dementia make informed decisions for as long as possible. The service will offer a point of contact for all information and advice as required. The service will signpost and support access to other appropriate support and services to ensure that people with dementia and their carers have access to the right help for them at the right time and are able to make the most of their abilities. The Dementia Adviser service will be new to Hounslow and will provide accurate and accessible information to help people with dementia make informed decisions for as long as possible. The Dementia Adviser will signpost and facilitate access to other services in Hounslow (such as Peer support groups and/or a referral to a Dementia Support worker, as appropriate to the needs of the person with dementia) and will link closely with the Care Navigators model. See Appendix 2 for Dementia Advisor Service outline. National Dementia GP contract Promote across Hounslow GP Practices The following changes to the GP contract for 2013/14, the Secretary of State for Health has directed the NHS England to establish an enhanced service to provide timely diagnosis and support for patients known to be at risk of dementia. NHS England seeks to invite and sign up GP practices to participate in this enhanced service by 30 June 2013. GP practices signing up to this enhanced service by 30 June 2013 will qualify for the component 1 payment. GPs will be paid to identify patients at risk of dementia and make an 'opportunistic offer' to assess them during a routine consultation. The list of at-risk patients includes all patients over 60 with cardiovascular disease or diabetes, as well as patients with learning difficulties or neurological conditions. GPs should then refer patients to memory clinics when dementia is suspected and offer treatment for memory loss. They will also need to offer health checks to carers of people with dementia. The average practice will receive 2,587 upfront to prepare for the service. Practices will then share 21m depending on the number of assessments they complete. See Appendix 3 for Dementia DES and payment outline. The Board are asked to agree to promote the rollout of the Dementia DES across GP practices in Hounslow. GP Locality meetings Those GP Practices with low dementia diagnostic rates may be a result of not recording the diagnosis correctly on the system. Therefore, Locality Meetings will be used to highlight this with all GP practices and target those ones that have a particularly poor diagnosis rate compared to their prevalence. The dementia template in QOF will be reviewed as this is seen as inadequate and needs a current Hounslow version. Page 12 of 23

Dementia CQUIN As part of the 2013/14 contract arrangements, WLMHT will be expected to deliver on the dementia CQUIN, which has 4 elements: Indicator 5a - WLMHT to send GP practices full and complete registers of all patients with a diagnosis of dementia under the Trust's care on a quarterly basis. Registers to include following information for each patient: Date and nature of last consultation at Trust Lead clinician/care coordinator at Trust Feedback on recent blood tests Cluster Mental health diagnostic coding WLMHT to continue with timely delivery of antipsychotic review outcome letters to GP/family/carers (within 3 working days) with a view to embed the process into business as usual. Indicator 5b - Building on the 2012/13 CQUIN investment, WLMHT to provide evidence of the implementation of the quality improvement plan to reduce inappropriate antipsychotic prescribing to people with dementia, with particular focus on providing an evidence based training programme across the full commissioner catchment area. Indicator 5c - Audit of antipsychotic reviews and evidence of a reduction in antipsychotic prescribing through the implementation of the action plan from 2012/13 POMH-UK audit results. Specific documentation to be evidenced: Risk/benefit analysis prior to initiating an antipsychotic Therapeutic response to antipsychotic Any antipsychotic related adverse events Indicator 5 d - Deliver a carers training programme, making better use of local investment in supporting carers training and with particular focus on social inclusion, carers of newly diagnosed dementia patients and access for those from under-represented groups. Thresholds for payments Most thresholds are still set at 90% positive satisfaction (with the exception of 5c which is set at 95% number of full and complete reviews). Links with other CCGs Hounslow CCG are working with Dementia commissioning leads in Ealing and Hammersmith and Fulham to ensure a consistent message and approach to reviewing WLMHT secondary care dementia services. Along with the three CCG GP Dementia leads the report will: o undertake a base line budget approach to clarify spend on specialist dementia services within WLMHT contract o develop KPI s and targets o review and develop activity and performance monitoring arrangements o develop one shared specification with separate schedules for the three boroughs Page 13 of 23

Appendix 1: Dementia Action Plan 2012-14 Update April 2013 Action 1. Mental Health Promotion and Prevention 1.1 Work with partners to understand the variation of use of dementia services across the borough and target campaign in the areas under represented. (NDS 1; NICE 3) 1.2 Develop an effective forum where people with dementia are able to inform service provision (NDS 5) 1.3 Deliver an information awareness campaign amongst practitioners of dementia and delirium, encouraging early help. (NDS 13; NICE 3, 8, 9) 1.4 Produce a directory of services which promotes advice and information on universal mental health and well being activities (NDS 1; NICE 3) 2. Early Intervention and Assessment 2.1 Work with GPs to identify and encourage early assessment of people with dementia and delirium. (NDS 2; NICE 1, 3, 4) Target Date July 2013 April 2013 Dec 2013 Mar 2014 Dec 2013 Measure of Success Update RAG rating Targeted local campaign delivered in health clinics, hospital and community venues reaching out to the widest range of communities Roll out of service user meetings and workshops Increase in the number of people referred for assessment of dementia Directory of services in place and accessible All GPs hold a register of patients diagnosed with dementia and offer to provide opportunities for screening risk factors associated with dementia, such as coronary Dementia steering group has been formed and includes partners from Hounslow CCG, WLMHT, WMUH, Housing and Alzheimer s Society. The group has looked at variation of use of dementia services. However no work has begun on a targeted campaign. No progress made. No progress made. No progress made. Using the dementia register work is underway to target GPs with low dementia rates. With CCG approval we hope to also actively promote the Dementia DES. Further Actions Submission for funds for Dementia Advisor to CCG Board To work with the Voluntary sector and WLMHT to develop a forum. Submission for funds for Dementia Advisor to CCG Board Submission for funds for Dementia Advisor to CCG Board To present dementia rates to GP practices at the next available locality meeting, Lead Partner(s) CCG/ LBH / Public health CCG/ LBH Voluntary Sector CCG/ LBH CCG/ LBH/ Voluntary sector CCG / WLMHT Page 14 of 23

Action Target Date Measure of Success Update RAG rating heart disease, stroke and diabetes Further Actions Lead Partner(s) 2.2 Use existing educational structures to train health practitioners to identify the early onset of dementia for people with learning disabilities (30 years +), particularly, distinguishing differences between challenging behaviour, dementia and delirium. (NDS 2; NICE 1, 3, 4) 2.3 Develop a database to record all people with dementia with the aim of improving the range of information, advice and support offered to people with dementia and their carers (NDS 1, 3; NICE 1, 3, 4) 2.4 Map and publicise dementia services and pathways to identify gaps/lack of capacity and to clarify what services are available. (NDS 2; NICE 1, 3, 4) 3. Treatment Mar 2014 Mar 2013 Mar 2013 Practitioners working with people with LD are aware of the increased risks and signs between challenging behaviour and dementia To screen people with down's syndrome from 30+ years old for dementia Database developed Directory of services in place and accessible Protocol to share information across agencies Network of dementia advisors/champions/care navigators Directory of services and pathway plans developed and is and accessible No progress made. No progress made. No progress made. Review the pathway for people with LD with Dementia Submission for funds for Dementia Advisor to CCG Board Submission for funds for Dementia Advisor to CCG Board CCG/ WLMHT/ HRCH CCG/ WLMHT/ HRCH/ LBH CCG/ WLMHT/ LBH 3.1 Develop a 24/7 psychiatric liaison service at WMUH to assess people who present in crisis and/or require specialist Mar 2014 Reduction the length of stay of patients with dementia in acute beds compared to 2011/12 baseline No progress made due to the pilot coming to an end and funding for service has not been committed. Acute commissioners are progressing the commissioning arrangements of the CCG/ WLMHT Page 15 of 23

Action mental health support. (NDS 8; NICE 8) 3.2 Develop current cognitive team to be able to respond quicker in times of crisis 3.3 Develop and agree a pathway for people with cognitive impairment, ensuring people are cared for in the most appropriate way (NDS 2; NICE 1, 3, 4) 3.4 Review the use of antipsychotic drugs for people with dementia across primary and secondary care and develop a strategy to reduce inappropriate use (NDS additional ; NICE 8, 9; CQUIN indicator 1, 2, 3) 4. Care and Support 4.1 Influence the development and roll out of the telephone support service, with a 24 hour emergency response, assistive technology and telecare to support carers of people with dementia (NDS 10; NICE 6, 10) 4.2 Develop activities in the Mental Health Day services which meet the needs of people with Target Date Mar 2013 Jan 2013 Mar 2013 Sept 2013 Dec 2013 Measure of Success Update RAG rating Psychiatric Liaison offered to care homes (virtual ward approach) Reduction the length of stay of patients with dementia in acute beds compared to 2011/12 baseline Reduction in the number of patients admitted as an inpatient compared to 2011/12 baseline Reduction in the number of antipsychotic drugs prescribed to people with dementia, especially those in care homes More people with dementia are receiving assistive technology and telecare support People with dementia are accessing community day services WLMHT are reviewing the dementia pathway as part of the WLMHT Transformation programme. Hounslow CID team have reviewed the pathway in light of the increasing waiting times and have ensured a consultant is available during office hours. WLMHT are reviewing a deciated phone support for primary care. As part of the CQUIN, antipsychotic drugs for people with dementia are regularly review. The use of antipsychotic in WLMHT is one of the lowest nationally. Hounslow CCG continues to commission a care home pharmacist service. LB Hounslow Reablement Team and Social workers are able to access people for Linkline (professional responder service) and Telecare (door sensors etc). Roll out has been slow and no data available. Have begun discussions with day opportunity providers, progress is slow as services are commissioned for 18-65 age Further Actions psychiatric liaison service with WMUH Commissioning managers across Hounslow, H&F and Ealing are rewriting the dementia specficiation WLMHT are reviewing the dementia pathway as part of the WLMHT Transformation programme. Completed and ongoing Ongoing roll out of provision Ongoing work with the day opportunity providers to further Lead Partner(s) CCG/ WLMHT CCG/ WLMHT CCG/ WLMHT LBH LBH/CCG Page 16 of 23

Action dementia (NDS 6; NICE 6, 10) 4.3 Develop the local market to meet the needs of people with dementia and their carers ready for the roll out of Personal Health Budgets 4.4 Promote the access of the Floating Support and Supporting Independence Services to people with dementia and their carers (NDS 10; NICE 3) 4.5 Influence the development of new supported housing schemes particularly, in borough extra care provision to support people with dementia (NDS 10; NICE 3) 4.6 Influence the new WLA domiciliary care framework to reflect the needs of people with dementia in Hounslow (NDS 6; NICE 6, 10) Target Date Mar 2014 Mar 2013 Mar 2014 Mar 2013 Measure of Success Update RAG rating group. At present the activites have been on increasing dementia awareness There are appropriate number Included within the 2013/14 commissioning of Personal Health Budgets Intentions, however, no progress as of yet. services to in the local market meet outcomes and needs More people with dementia access floating support services and supporting independence services allowing them to remain independent and stay at home Increase in the extra care provision for people with dementia Increase in the range of domiciliary care services for people with dementia Representative from SIS atteneded Carers Forum Meeting to promote services and a pathway has been developed for referrals from Carers. The SIS have visited Brentford Lodge Memory Clinic to discuss Supporting People services including floating support services with staff. The SIS and floating support services have supported increased numbers of clients with dementia including supporting them to be discharged from hospital into assessment flats onto sheltered accommodation and into Extra Care Housing. The new Extra Care Housing scheme which has recently been granted planning permission has been designed as dementia friendly. It has been designed with the option to have a dementia specific wing if needed. Mental health commissioning fed into the specification of the framework. Further Actions develop their dementia provisions Work developing as part of the Adult Social Care transformation agenda and systems to be agreed To monitor number of service users with dementia and carers are coming through the SIS. Continue to factor dementia features into new build supported housing schemes where appropriate The Contract start date will be March 2014. Lead Partner(s) LBH/CCG LBH LBH LBH Page 17 of 23

Action 4.7 Work with care homes in Hounslow to identify a staff member to champion dementia within the setting (NDS 11; NICE 8, 9) 5. Ensuring Quality for Older People 5.1 Develop clearer links between acute, mental health services, community services and social care when supporting people with dementia and delirium. (NDS 9; NICE 8, 9; CQUIN indicator 4) 5.2 Influence the newly commissioned carers services to offer outreach support to carers of people with dementia (NDS 7; NICE 6, 10) 5.3 Mental health teams identify carers and are referred to services for respite, information and support services (NDS 7; NICE 6, 10) Target Date Sept 2013 Mar 2013 Mar 2013 Sept 2013 Measure of Success Update RAG rating Care homes are able to Care home Working Group formed and provide evidence of dementia intital discussions undertaken with project awareness training and wider lead. benefits to people with dementia and challenging behaviour in their settings. People with dementia receive a seamless service Agreed referral routes, timescales, clear responsibilities and protocol for joint working including the role of community dental service Reduction in re-admission rates Carers groups and peer support network developed Increase in the number of carers being referred from mental health teams to voluntary agencies Carers groups and peer support network developed Dementia steering group has been formed and includes partners from Hounslow CCG, WLMHT, WMUH, Housing and Alzheimer s Society. The group has looked at variation of use of dementia services. The outreach service offering support to Carers of people with dementia was awarded to INS (Integrated neurological services). The Service is busy recruiting staff and a manager. Once they are in place, the service will be able to accept referrals into the service. The Carers assessors in the Mental health teams have been assessing Carers of service users at Brentford Lodge. Part of the assessment process involves assessing the needs of these Carers, signposting and referring Carers into support services and offering direct payments where Further Actions Progress with care home project lead and LBH contracts team Board meeting every two months to review different elements of the dementia pathway Completed and ongoing Completed and ongoing Lead Partner(s) LBH CCG/ WLMHT/ LBH LBH / CCG LBH / CCG Page 18 of 23

Action 5.4 Deliver an information awareness campaign that raises the awareness of the importance of Co-Ordinate my Care i.e. EOL care planning amongst GPs for people with dementia (NDS 12; NICE 8, 9). Target Date Mar 2013 Measure of Success Update RAG rating appropriate. People with dementia nearing All GP practices have been trained, their end of life and their specialist palliative care staff, care homes carers are able to access EOL and HRCH nurses. The Coordinate my Care services register went live with the soft launch of 111 in March 2013. The patients being put on the register is being monitored by one of the locality managers. Further Actions Completed and ongoing Lead Partner(s) CCG Page 19 of 23

Appendix 2: Hounslow Dementia Adviser Service Dementia Advisers will provide personalised information, advice and signposting services to people in the process of getting a diagnosis or from diagnosis of dementia onwards. Dementia Advisers will provide accurate, accessible information to help people with dementia make informed decisions for as long as possible. The service will offer a point of contact for all information and advice as required. The service will signpost and support access to other appropriate support and services to ensure that people with dementia and their carers have access to the right help for them at the right time and are able to make the most of their abilities. The Dementia Adviser service will be new to Hounslow and will provide accurate and accessible information to help people with dementia make informed decisions for as long as possible. The Dementia Adviser will signpost and facilitate access to other services in Hounslow (such as Peer support groups and/or a referral to a Dementia Support worker, as appropriate to the needs of the person with dementia). Evidence that the service is needed The service is co-designed by people with dementia and their carers who said they would benefit from sitting down face-to-face with someone shortly after diagnosis to plan for the journey ahead and that information should be communicated in an informal and friendly way. People with dementia and carers co-designed the information tool kit and guidebook (online database local services) resource made available to people through the Dementia Adviser service. The Dementia Adviser will provide a clear referral pathway to ensure people with dementia and their carers receive the correct information at the right time throughout their journey with dementia. Evidence of the effectiveness of the proposed service model The effectiveness of the service has been developed following the implementation of three early pathfinder sites in England and the further implementation of Department of Health demonstrator sites. Evaluation of the pathfinder sites demonstrated the value of working directly with people with dementia and their feedback and comments on the service has enhanced provision. The main findings indicate the value of the service in terms of identifying unmet and unknown information needs and responding to these as they arise. The significant number of service users who do not have a carer also indicates a need for facilitated access to information normally provided through carers or family to those who live alone. There is growing evidence to support the effectiveness of information and advice services in improving outcomes for people with dementia and their carers, where information and advice is supplemented by other elements of support such as help with navigating health and social care services. Improvements in quality of life, and reductions in carer burden or stress have been noted. The Dementia Adviser will also delivered awareness raising presentations to various community groups and developed referral pathways in GP practices, with Practice Nurses and other Secondary Care Professionals and voluntary organisations. Page 20 of 23

Support and resources we will deliver Dementia Advisers are an integral part of the local information and support pathway offered by the Society to support people with dementia, their carers and family throughout the person with dementia s life. They complement the National Helpline and other local services in Hounslow including the information service, Dementia support service, Peer support groups and Carers Information programme. The Dementia Adviser service will take referrals from other dementia services in Hounslow internally and will refer to other Society services or providers when more complex and intensive support is required. The Dementia Adviser service will provide information, advice and signposting to service users in Hounslow: In order to deliver this, the Dementia Adviser will map the current provision of dementia services within the London borough of Hounslow and this will form the basis of the Guide which will be available in both hard and electronic copies. The Dementia Adviser service has the full support of a sophisticated database which also provides gap analysis as a result of service user involvement. Information An information service will give service users the information they need. It can include information about rights, policies and practises; and about national and local services and agencies. An information service includes: providing general information e.g. factsheets and leaflets signposting e.g. providing factual information about the role of another organisation or how to find or contact that organisation assisting service users to find information that relates to their enquiry e.g. providing the service user with leaflets, website addresses or other details which will help them contact other organisations. Advice An advice service gives service users more specialised information. It involves: identifying the service user information and health and social care needs giving information and explaining options identifying further action the service user can take can involve some assistance e.g. contacting third parties to seek information. An advisory service includes: providing information on matters relevant to the problem signposting a service user to another source of help, having first assessed the nature of the query and the level of advice or help needed, including signposting to legal and welfare specialists. Signposting A signposting service involves: identifying other services within the Society and external organisations that may assist service users providing information about appropriate services to service users. Who will deliver the service The Service will be delivered by a full time Dementia Adviser with the support of fully trained Dementia Adviser volunteers, this service will be available Monday to Fridays during core hours of 9am to 5pm and based at Brentford Lodge. Page 21 of 23