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Dr Nicholas John Consultant Geriatrician RUH Bath

National Dementia Strategy Objective 8 Improved Care in acute hospitals-how can we achieve this and save money!?. Dr Nicholas John Consultant Geriatrician RUH Bath. The Scale of the problem. In UK >700,000 people diagnosed with dementia

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Dr Nicholas John Consultant Geriatrician RUH Bath

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  1. National Dementia Strategy Objective 8 Improved Care in acute hospitals-how can we achieve this and save money!? Dr Nicholas John Consultant Geriatrician RUH Bath

  2. The Scale of the problem • In UK >700,000 people diagnosed with dementia • In South west 73,000 increasing to 102,000 by 2025(41%↑) • Only 1 in 3 get a diagnosis EVER • More people retire to the south west and their life expectancy is the highest in the country • NHS Devon will have the highest number of dementia cases in the country by 2025

  3. In Hospital • ¼ of all beds occupied by patients over 65 with dementia • Higher rates of placement, mortality and morbidity and longer length of stay for all conditions • Lincs study showed 60% of patients with dementia in acute beds did not need to be there • NAO suggests these factors cost each acute hospital £6million per year

  4. Is Bath special? • BaNES and Wiltshire have about 1/3 cases on the QOF dementia and are in bottom 1/3 for “diagnosis gap” and Cognition enhancer prescription in the country • 122 elderly care patients with “seasonal” outliers • MH liaison provided by MH nurses • 7 Community hospitals over 4 PCT’s

  5. The Bath Story so far • Oct 2007 Bath area conference of Old Age Medicine and Psychiatry to identify areas for improvement • Jun 2008 CSIP case note audit of 34 dementia patients at RUH • July 2008 Multiagency workshop to develop action plan • Sept 2008 RUH dementia stakeholder group established • Feb 2009 Trust wide survey of cognitive impairment • June-July 2009 SW SHA dementia review of BaNES and Wiltshire • January 2010 Action Plan agreed to capitalise on progress so far and attempt to complete objectives of NDS

  6. Initial case note review 2008 • Early information gathering is vital • Environmental factors are contributing to problems • Staff education and awareness lacking • “Medicalisation” of decision making • No whole system working • Risk averse culture to discharge

  7. Cognitive survey 2009 • 6 Wards with large elderly focus • 34% had cognitive impairment • Average LOS 25.4 days (up to 98 in some cases) • Only 50% had any diagnoses • 14% currently known to MH services • Only 34% had any test of cognition • Orthopaedic #NOF proforma had a 90% MTS completion rate

  8. 2009 SHA dementia review • Peer review • Baseline assessment • Good practice highlighted • Deficits identified • Advice re implementation of the NDS • Action plan developed with timeline

  9. SHA review key findings • Chief officers from acute trusts often absent • User feedback very negative particularly food and drink, staff awareness and frequent moves • Dementia not a corporate priority and mainly a care of the elderly issue • Discharge delays due to difficulties with social services, access to intermediate care, CHC screening and lack of MH input • MH Liaison services usually unidisciplinary

  10. However…. • Many examples of innovative practice • Liaison nurses in Cornwall inreaching into Care Homes to minimise acute transfer • “Life story” books • Rotation of AHP’s through MH and acute trusts • Clothing ID system (B&Poole) • Day ward for wanderers in Dorchester • GP Academy in Cornwall

  11. Positive practice cont., • PAINAD scoring system in Cornwall • Rehab units with dual trained RGN/RMN (Poole) • “Grab sheets” and “message in a bottle” • CHC screening and allocation without panel (B&Poole) • Dashboard bed management in Torbay • Dementia specific intermediate care • Bristol MH liaison team ↓LOS by 3-4 days and saved £1million pa

  12. SHA action plan 2009/10 • 7 priority areas: • Early intervention and diagnosis for all • Improved community personal support • Implementing New Deal for carers • Improved care in acute hospitals • Living well in care homes • Informed and effective work force • Joint commissioning for dementia

  13. Financial constraints • NAO report Jan 2010 • NDS implementation cost £1.9 billion • Funding by efficiency savings only £500 million • £150 million new money not ringfenced and no responsibility to show how money spent • Dementia not in Operating Framework “Vital signs”

  14. So an impossible task? • Executive sign-up • NHS 2010-15 will be a time of belt tightening • PCT payments to acute trusts will change from April with emphasis on reducing excess bed days in the setting of no increase and some reduction in tariff • Trust boards need to see tackling dementia will reduce bed stays reducing outliers and allowing 18 week RTT targets and 4 hour waits to be met • Dementia steering groups with executive presence will facilitate these discussions

  15. How to do it • Information gathering • Early cognitive assessment allowing discharge process blocks to be identified early • Dementia care pathway with cognitive algorithm (BGS/RCPsych) so every one knows what they are doing-dementia website helpful • Carer involvement early

  16. How to do it • Partnership working • Meet your commissioners! • Consider CQUIN schemes for dementia eg participation in national dementia audit • Clinical involvement in World Class Commissioning is key to success • Identify the outcomes you both want and how to achieve them

  17. How to do it • Patient/carer involvement • National Operating Framework will increasingly require evidence of user involvement to reward acute trusts • Patient Experience Tracker is a very powerful tool • Use your local voluntary sector-they are desperate to be involved more

  18. How to do it • Mainstreaming dementia care • Dementia training needs to be mandatory for all acute trust staff with records kept of uptake of training • Engagement of non-elderly care staff challenging but ward based dementia champions and incentive backed trust dementia chartermarks are one way

  19. How to do it • Benchmarking and data • National dementia audit starts Mar 2010 • DOH dementia portal has some dementia metrics available from south coast SHA • SHA “must-do’s” • Clinical dementia lead • Care pathway in situ and evaluated • OPMH liaison teams • Training all staff in dementia

  20. How to do it • Others locally developed might include: • LOS data for dementia and non dementia including subspecialty eg #NOF • Discharge destination • Anti-psychotic prescriptions • Ward moves • Nutritional assessments • DOLS/MCA/MHA assessments • Environmental surveys • Quality of information on wards

  21. Summary • Don’t despair! • Make dementia core business • Commissioning relationships are of increasing importance • User viewpoint will become an important lever • Get it right for dementia and everybody will benefit

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