South Norfolk CCG Dementia Strategy and Action Plan Dr Tony Palframan, SNCCG Governing Body Member

Agenda item: 9.4 Subject: Presented by: Submitted to: South Norfolk CCG Dementia Strategy and Action Plan Dr Tony Palframan, SNCCG Governing Body Member Governing Body Date: 28 th July Purpose of paper: To ratify the South Norfolk CCG Dementia Strategy and Action Plan. Executive Summary: 1.1 The development of a South Norfolk CCG Dementia Strategy and Action Plan is encompassed within the Better Care Fund (BCF) Dementia Workstream Plan. The need for a strategy and action plan was also requested from NHS England as part of the drive to improve dementia diagnosis rates and reach the national ambition of 67%. 1.2 The final plan (see Appendix A) aims to ensure that SNCCG s approach to improving the rates of dementia diagnosis and in further developing the South Norfolk dementia care pathways, continues to be embedded within the BCF programme and that it works within both county and national strategic ambitions for dementia care and support. 1.3 Dementia diagnosis in South Norfolk is currently at 54.1% against a target of 67%. A trajectory to reach the required standard by December has been agreed with NHS England. This will require a proactive approach of working with Primary Care other the next six months, concentrating on those practices within the lowest quartile of dementia diagnosis rates. These practices will also be asked to send the CCG copies of their dementia register submissions on a monthly basis. 1.4 Feedback on the draft from the Area Team and Strategic Clinical Network has been received and was positive. One of the areas highlighted for SNCCG to consider further is the role of care homes in supporting dementia diagnosis and the care of patients in home within the dementia pathway. Further support has been offered to the CCG with regards to these aspects. Adjustments in accordance with this feedback have been made. 1.5 Governing Body members are asked to note that the CCG is not currently receiving monthly dementia diagnosis QOF data returns from NHS England, due to issues with HSCIC. These are not expected to be back in place until September and so the CCG cannot currently assess progress against the trajectory or provide practices with an up to date measure of performance. Recommendation: The Governing Body is asked to ratify the final strategy and action plan. 1

Key Risks Clinical: Finance and Performance: Impact Assessment (environmental and equalities): Reputation: Legal: Resource Required: Reference document(s): None identified The CCG is not currently meeting it expected performance in relation to dementia diagnosis the aim of the action plan is to help support this within the agreed trajectory set out. The action plan as set out does not require any additional funding resources for implementation. N/A None identified None identified Clinical expertise is in place to support the implementation of the action plan. However a clear SNCCG management lead to oversee and drive forward the plans implementation needs to be identified from within existing resources. Not applicable. NHS Constitution: Conflicts of Interest: None identified. GOVERNANCE Process/Committee approval with date(s) (as appropriate) For approval at the July Governing Body. 2

Appendix 1: Final Dementia Strategy and Action Plan South Norfolk Clinical Commissioning Group Dementia Strategy and Action Plan: to 2017 Introduction This strategy sets out progress that South Norfolk CCG will take with partners and services to improve dementia diagnosis rates, services and outcomes for people with dementia and their carers in South Norfolk. The strategy and action plan have been developed to support progress against national, county and CCG level priorities. It forms a core workstream within the CCG s Better Care Fund (BCF) plan, with the aim of ensuring that actions and developments are taken forward within a wider vision of integrated care and services in South Norfolk. SNCCG believe that implementing this strategy will: Improve people s experience of having dementia and the services they receive and so will the experiences of families and carers. Increase levels of awareness and understanding of dementia amongst the public and service providers, helping to reduce the stigma associated with dementia. Ensure a higher proportion of people receive a timely dementia diagnosis. National Context In 2009, Living Well with Dementia - a National Dementia Strategy i was issued. This set out new standards for dementia care focusing on improved awareness, earlier diagnosis and intervention and a higher quality of care. In 2010 by Quality Outcomes ii for people with dementia were published, these built on the work of the national strategy and dementia NICE guidance iii. The Strategy s ambitions were reinforced in 2012 by launch of the The Dementia Challenge: responding to a National Priority iv which provided a focus on speeding up the raising of diagnosis rates and improving the skills and awareness needed to support people with dementia and their carers. Geographical performance in the identification and management of Dementia across England was highlighted in the 2013 Dementia: A state of the nation report on dementia care and support in England v which also promoted the development of Dementia Friendly communities. More recently in February the Department of Health (DoH) issued the Prime Minister s Challenge on Dementia 2020. With a key objective that by 2020 England will be the the best country in the world for dementia care and support for people with dementia, their carers and families to live vi. Throughout this the importance of ensuring that people with dementia and their carers are at the heart of everything that is taken forward to realise this vision. The visions main objectives include: 3 Improved public awareness and understanding of the factors, which increase the risk of developing dementia and how people can reduce their risk by living more healthily. People with dementia having equal access to diagnosis, with an expectation that the national average for an initial assessment should be 6 weeks following a referral from a GP (where clinically appropriate).

Every person diagnosed with dementia having meaningful care following their diagnosis, which supports them and those around them. All NHS staff having received training on dementia appropriate to their role. An additional 3 million Dementia Friends in England all hospitals and care homes meeting agreed criteria to becoming a dementia friendly health and care setting. GPs playing a leading role in ensuring coordination and continuity of care for people with dementia. From 1 April everyone will have access to a named GP with overall responsibility and oversight for their care. Over half of people living in areas that have been recognised as Dementia Friendly Communities Norfolk Picture Dementia is one of the three priorities within the Norfolk Health and Wellbeing Board 2014 2017 strategy. This aims to make Norfolk a better place for people with dementia and their carers. The objectives contained within this priority are to: 1. Promote awareness of dementia 2. Build an integrated approach to dementia 3. Improve the managed dementia care pathway 4. Support independent living in the community 5. Improve services for those unable to live independently The strategy highlights how: The prevalence of dementia is rising both nationally and in Norfolk. Dementia is principally a disease of older people and Norfolk has a higher proportion of people over 65 than the England average. It is estimated that nearly two thirds of people with dementia in Norfolk have not had a formal diagnosis of their condition and that over the next ten years the number of people with dementia will increase by about 5,000. vii The strategy was built upon the findings of a Norfolk Dementia needs assessment viii. The assessment highlighted the following: 4 There are about 26 new cases of dementia per year per 1000 population of over 65s in Norfolk (diagnosed or undiagnosed). Just over half of people with dementia have mild dementia and the remaining have moderate or severe. People with dementia find it difficult to feel part of, and participate in, their community in Norfolk. People identified several attributes they wanted from their community which included awareness, support groups, clearer information, and supportive physical environment, activities at the right level, good transport and local amenities. Feedback from people with dementia and their carers indicated that people want to know their diagnosis. There needs to be a step change in the diagnosis rate if the national NHS England target of 67% is reached. People felt that the quality of services provided within Norfolk is good but that there remain capacity issues. About 1 in 3 to 1in 5 people in hospital have dementia. There is a reluctance across some GPs to refer to diagnosis, because they see little point diagnosing dementia as they perceive that there are no or limited services to support people with dementia and their carers after diagnosis.

The assessment recommendations included the following: CCGs should ensure GPs are aware of available support for people with dementia and their carers. Commissioners and providers should work together to help more people with dementia die in their place of choice. Health and social care should jointly commission dementia support services. Dementia friendly communities should extend to non-geographical communities. CCGs should assist GP practices to standardise dementia coding and undertake coding audits. Providers especially acute hospitals, community healthcare, care homes and domiciliary care organisations, should include essential dementia skills and knowledge in their job descriptions when recruiting staff and use dementia coaches for workforce development. Commissioners and providers should work together to develop joint referral pathways and where appropriate agree tools. SNCCG Dementia Strategy The Norfolk dementia needs assessment estimates that in there will be 3792 people with dementia in the South Norfolk CCG area. The CCG has been working with GPs and services to increase dementia diagnosis rates. The latest data available (March ) via the dementia prevalence calculator showed that overall diagnosis rates were at 54.1%. This identifies an estimated gap of 1,661 people who may benefit from access to support by way of a dementia diagnosis, and a gap of 456 to achieve the national ambition. As outlined within the introduction SNCCG has sought to ensure that dementia is considered as a core part of developments to increase integrated care and provision through the implementation of the BCF and this strategy has been developed in accordance with the BCF priorities and planned work programme. The overarching objective within this workstream is: There is good information, advice and services for people with dementia and their carers so that people in South Norfolk are more confident that there are support services available following diagnoses. The strategy has been built on the outcomes of a Dementia Co-Production event SNCCG held in December 2014. This valuable event highlighted the following key messages about what works well and what could be better. What is Good in South Norfolk? What could be better in South Norfolk? Carers support groups Admiral Nurses Assistive technology medication reminders, medication carousels, movement sensors Improving diagnosis rates That South Norfolk is focussing on mental health and dementia Early support Co-ordination of services Single Point of access Information that is easily accessible Dementia support workers Improved integration and joined up services 5

The achievements made to date and next step developments that SNCCG plan to take forward within each of the SNCCG BCF priorities are outlined below. Priority 1: To set up a pilot for dementia planning beds in Dereham. Priority aims: to ensure the provision of residential care for people with dementia who no longer need to be in an acute hospital setting. Thus enabling people to receive ongoing care outside of acute settings and potentially reducing hospital length of stays. Progress in 2014/15 the pilot has been set up, running and is due to end in July. Norfolk County Council is now looking at a new and more reablement based approach to supporting people, including people with dementia, who do not need to be in an acute setting. The use of temporary residential care beds to provide space of individuals and families to establish the best setting in which to meet their ongoing care needs encourages by its nature people to consider a permanent care home admission. Developments for to 2017 The pilot will be reviewed during the 2 nd quarter of, in the context of review that Norfolk County Council is undertaking. With the findings, outcomes and recommendations from this identified and considered by the SNCCG BCF Dementia Workstream Project Group. Priority 2: Develop and implement a plan for increased diagnosis as part of a clear communications and engagement plan to patients and members of the public. Priority aims: this priority has two clear aims. Firstly to deliver a robust communications and engagement plan with stakeholders, patients and carers, with the outcome of increasing awareness of dementia and encouraging more people to contact their GP for a diagnosis and support; and secondly to ensure increased numbers of people are diagnosed with dementia in line with national NHS England expectations of 67% of people estimated to have dementia being diagnosed. Progress in 2014/15: SNCCG worked over the year to support GP Practices in increasing the diagnosis dementia rates. These actions included; encouraging surgeries to complete dementia diagnosis register clear up exercises, keeping surgeries informed on a monthly basis of the CCG and each practices progress against the dementia diagnosis target and; providing surgeries with good practice examples of actions they can take forward to help improve dementia diagnosis register rates. SNCCG also identified further work needed to improve the quality of communications between the mental health secondary care service provider and primary care to ensure that dementia diagnosis is clear within communications. Lastly the CCG worked to support wider dementia related communications and public awareness campaigns including within this the development of and communications relating to dementia friendly communities. 6 Developments for to 2017: despite progress against the dementia diagnosis target, SNCCG remains some way below the expected level of 67%. During /16 the numbers confirmed with a dementia diagnosis per month needs to rise at a faster rate compared to the rate of diagnoses made in 2014/15. This means that to reach the expected levels within the year the rate diagnosed per month needs to be at least a further 2.5% above those already captured on GP registers, or an equivalent of 3-4 people per practice. A forecast dementia trajectory based on this is provided in the below graph and table.

Apr- 15 May -15 Jun- 15 Jul- 15 Aug -15 Sep- 15 Oct- 15 Nov -15 Dec- 15 Estimated numbers of people with dementia 3552 3552 3552 3552 3552 3552 3552 3552 3552 3552 3552 3552 Prevalence Target 67% 67% 67% 67% 67% 67% 67% 67% 67% 67% 67% 67% Dementia QOF register trajectory 1972 2024 2078 2133 2190 2248 2308 2369 2432 2448 2465 2481 Numbers to be identified in month 17 52 54 55 57 58 60 61 66 16 17 16 Performance % trajectory 55.5 57.0 58.5 60.1 61.6 63.3 65.0 66.7 68.5 68.9 69.4 69.9 Jan- 16 Feb- 16 In order to progress against this trajectory SNCCG will continue with the actions already being taken forward but will also work more proactively with those surgeries in the lowest quartile of dementia diagnosis rates to aid the identification of reasons for why they are not progressing as well as other surgeries and to identify actions that they can take forward to improve performance. SNCCG will continue to monitor the performance of the dementia diagnosis rates completed by the Norfolk and Suffolk Foundation Trust (NSFT) and ensure that actions already agreed to improve communications from the Trust to GPs following a dementia assessment are taken forward and to identify new actions as needed. The outcomes of the above work will be reviewed in Q3 of /16 to ensure any further developments required in 2016/17 are identified and planned. SNCCG will also work to further develop its communications and engagement work over the next two years, building on the work taken forward in 2014/15 to do this. Mar- 16 7

SNCCG will also review and consider the evidence base for good working practice relating to the identification, diagnosis and support needs of people with dementia within care homes. The CCG will then use this evidence base to identify potential options for implementation and to engage care homes in their roles during the last quarter of /16 and into 2017/18. Priority 3: To ensure the provision of good information and easy access to a range of services for people with dementia and carers post diagnosis. Priority aims: this priority builds on priority 2 and focuses on information and services for people with a dementia diagnosis and the needs of their carers. The aim is to ensure that post diagnosis people feel and are fully supported in accordance with their needs and that Primary Care feel confident that there are easily accessible pathways and support services for people. Progress in 2014/15: Work commenced during this year in reviewing the existing services within South Norfolk to people diagnosed with dementia and support to their carers. SNCCG funds the Alzheimer s Society for the provision of information, advice and advocacy for people with dementia along jointly with Norfolk County Council and other Norfolk CCGs. This is part of a commissioned partnership model for information and advice which also includes a service for older people provided by Age UK meets dementia related information needs as part of its provision. As part of the review work SNCCG considered the outcomes of an Admiral Nurse pilot that had been delivered within the Mid Norfolk locality and worked with the provider to agree continued delivery of an Admiral Nurse service taking this out across the wider SNCCG area. SNCCG in tandem with the other CCGs also funds the Alzheimer s Society to provide dementia support workers. Within SNCCG there are four locality areas made up of a number of GP surgeries who work together. These localities developed and secured funding from the CCG to implement plans to improve outcomes and hospital attendance and admission rates for patients aged over 75. Within these over 75 plans the localities have further supported dementia service development through contributing to the funding of the Admiral Nurse services and in two areas seeking to fund extra dementia nursing capacity. The work taken forward in these areas aims to support and further develop integrated approaches to care and services and the dementia aspects of the plans will also work within this integrated approach. Another key area of focus within the plans is on Care Homes and the support to them from both Primary Care and secondary care services. The CCG also commenced work on considering the pathways of care for people with dementia, linking into wider work within Norfolk taking forward in relation to this. SNCCG secured funding for a short term dementia pathways post. Developments for to 2017: during the main priority will be to complete the dementia pathways review work. With the Dementia Pathways Worker completing this during the summer period making recommendations about effective pathways of care and services by September. This work will inform the CCGs commissioning intentions and service developments for implementation in the 2016/17 year. The CCG will monitor progress and outcomes of investments made in dementia support services over the /16 year feeding this into the outcomes of the pathways review work and utilising this information to help inform future developments. This will include 8

reviewing the impact and outcomes of the dementia elements within the CCG Localities Over 75 plans. North Norfolk CCG and the Alzheimer s Society have developed and are trialling an information pack in memory clinics, GP practices and other settings for people with dementia. SNCCG will consider the effectiveness of this work as part of the review of dementia pathways with a view to making recommendations about use of the approach in South Norfolk. SNCCG is leading as part of the integrated commissioning team in a review of these information and advice services including dementia support. Recommendations made to SNCCG about the shape of these services and their best fit in dementia pathways will be picked up through the dementia pathways work in Q1 and 2 of /16. Priority 4: Continue the development of/support for dementia related community initiatives and review current training on dementia available to care organisations Priority aims: this priority aims to help the development of community related initiatives such as Dementia Friendly Communities and support networks across SNCCG with the desired outcome of ensuring more people with dementia and their carers feel supported within their communities and are less isolated. The priority also aims to ensure that care organisations are better able to support people with dementia through working to review current training and seeking options for the further development of this. Progress in 2014/15: SNCCG has written a dementia resource list for South Norfolk GP practices and contributed to a new Norfolk wide dementia website. Information has been gathered on current dementia training available in South Norfolk work has progressed to discuss training needs with GPs. We have supported the Dementia books on prescription project. We have supported a Breckland District Council initiative to make their leisure centres dementia and carer friendly through providing training for staff and a tailored leisure based activity programme for people with dementia and respite for carers. Developments for to 2017 We will continue to work closely with District Council County Council and voluntary sector partners to support and develop integrated community/ prevention initiatives: the development of new dementia friendly communities; promoting the use of dementia community hubs ; supporting independence at home through assistive technology advice and support services. We will work collaboratively with the County Council on the planned re-commissioning of homecare services to ensure there are services confident, trained and skilled in supporting people with dementia We will develop a GP dementia training programme and work with partners to identify ways to meet training needs across the health and social care sector including in care homes. Reporting and Governance Progress against the strategy and action plan will be overseen on a monthly basis by the SNCCG BCF Dementia Workstream. This workstream will report developments to the SNCCG Governing Body and Leadership Team meetings via regular updates within the CCGs Commissioning Report and formal papers when decisions are needed that require Governing Body approval. The strategy will be reviewed in Q4 of and where needed refreshed. The action plan for 2016 will be developed for implementation in the 2016/17 year. 9

SNCCG members will be kept up to date on strategy implementation via quarterly updates within the SNCCG Members Newsletter and members of the public will be informed through ongoing communications including, website, attendance and Patient and Participation Groups. Leadership for the strategies implementation will be supported within the CCG by a Clinical Lead, who will champion the work being taken forward, provide clinical advice and governance and support strategy implementation. 10

SNCCG Dementia Strategy Action Plan /16 Priority To set up a pilot for dementia planning beds in Dereham. Actions & Tasks Planned Completion Date Pilot established. Review to be completed. Sept Develop and implement a plan for increased diagnosis as part of a clear communications and engagement plan to patients and members of the public. 11 Monthly updates to GP surgeries re performance Gain agreement from surgeries within lowest quartile of performance to return monthly updates to CCG Monthly reporting from surgeries in lowest quartile commences Targeted support offered to surgeries within lowest quartile to identify opportunities to increase dementia diagnosis rates and ensure the capture of all diagnoses within surgery register. Regular GP Dementia Clinical Newsletter, providing useful information on dementia diagnosis, services, updates on strategy implementation. Lead by SNCCG Clinical Lead GP dementia education session follow up from initial session held in November 2014 Monthly monitoring to NSFT dementia assessment rates Improved dementia assessment communications to Primary Care by NSFT Memory assessment capacity within NSFT for the SNCCG area reviewed Via website, newsletters and wider engagement communicate the aims and objectives of the SNCCG Dementia Strategy to the following groups: General Public People with dementia and their carers Primary Care Commissioned and local agencies and providers Stakeholders and partners Support Dementia Awareness Week via CCG attendance at public events and via SNCCG website information. Communication and engagement with carers at Southern Locality Carers Council meeting and Carers Council for Norfolk meeting. April to March 2016 July July March 2016 July onwards. July onwards February 2016 April onwards June onwards September From June onwards to March 2016. End May Southern Locality Carers meetings June 15, September

15, December 15 and March 16. Carers council for Norfolk quarterly. To ensure the provision of good information and easy access to a range of services for people with dementia and carers post diagnosis. Continue the development of/support for dementia related community initiatives and review current training on dementia available to care organisations. Engage patient involvement in the championing of dementia awareness, via engagement of patient and participation groups and services. Review dementia pathways including the evidence about the effectiveness of current services Use dementia pathways review as basis for commissioning recommendations from 2016/17 onwards Monitor progress and outcomes of Admiral Nurse provision Support the promotion and awareness of Dementia Information Packs following a review of their effectiveness through the pilot in North Norfolk Promote awareness of Admiral Nurses and the services provided, supporting the engagement within Primary Care and local patient groups. Review of information and advice services including dementia support. Recommendations made to SNCCG about the shape of these services and their best fit in dementia pathways will be picked up through the dementia pathways work in Q1 and 2 of /16. GP dementia education programme Support the promotion and development of Dementia Friendly Communities in South Norfolk. Strategically support and promote the activities designed and delivered by District Councils in the SNCCG area. Encouraging patient involvement and public awareness in services such as the Dementia Activities Scheme and South Norfolk District Councils Early Help project. Re-commissioning of home care services in South Norfolk ensuring within this a key focus on dementia support and training. Ongoing Complete by end of Sept October To end of March 2016 Launch May Ongoing to March 2016 October September March 2016 Ongoing Ongoing February 2016 onwards i Living Well With Dementia: a national dementia strategy. February 2009. https://www.gov.uk/government/publications/living-well-with-dementia-a-national-dementia-strategy ii Quality outcomes for people with dementia: Building on the work of the national dementia strategy. September 2010. https://www.gov.uk/government/publications/quality-outcomes-for-people-with-dementia-building-onthe-work-of-the-national-dementia-strategy iii To be completed 12

iv Prime Minister s challenge on dementia: Delivering major improvements in dementia care and research by. March 2012. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215101/dh_133176.pdf v Dementia; A state of the nation report on dementia care and support in England (DoH), November 2013. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/262139/dementia.pdf vi Prime Minister's challenge on dementia 2020. February. https://www.gov.uk/government/publications/prime-ministers-challenge-on-dementia-2020 vii Joint Health and Wellbeing Strategy 2014-2017. A report to the Norfolk Health and Wellbeing Board. May 2016. viii Living in Norfolk with Dementia: A Health and Wellbeing Needs Assessment. July 2014. Norfolk County Council Public Health wwww.norfolk.gov.uk 13