The Business Case for Dementia Care

1. The Business Case for Dementia Care Mike Tullett MKBCA January 2011

2. What is dementia? • An umbrella term taking in over 30 types • A difficult medical diagnosis • 4 main types- AD, Vas Dem, Mixed, Lewy Body • Different presentations but all hold characteristics of • Loss of cognitive function • Altered behaviour • Some extension of the person’s life course • A PROGRESSIVE CONDITION

3. Demography • 614000 people aged 65yrs plus have dementia in UK (POPPI 2010*) • The National age related ratio is 1:13/65yrs * • Predictions are for a rise of nearly 400000* in 20 yrs, giving an increase in dementia of 200 cases per year. • Population of Bucks is currently 479000 of which 32000 (14%)are male over 65 yrs and 40000 (16.4%)are female. • Baseline figures would indicate 5500 PWD in Bucks.

4. Local demographics • The local Health Profile (Bucks 2008) identifies 15000 people with Vascular disease; 2279 people with Ca; 5000 with COPD. In comparison there are likely to be 5500 with dementia although official figures are not available. • Added to this, the profile expects MK older population to grow by 248% in the next decade. This will add to the 200 new cases of dementia predicted per year.

5. Local Provision • There are currently estimated to be 2700 beds for PWD in the locality (67 homes: Range 4-120 beds). • The Alzheimer’s Society estimate 40% of PWD are requiring Residential Care. By statistics we have an overload of available beds of some 500 at this time. • Some alteration is expected in the light of funding cuts to LAs, but it is clear dementia care is not an easy option, at least for the next 2-3 years.

6. Government Policy • It is clear the changes in the NHS are unclear at this time. • However, the emphasis of care is placed upon the community and upon families to look after their own. • The myth put out by the Government is that dementia is an illness that may be relatively static. The use of anti-D drugs and CST are being relied upon to stem the progression. • In contrast, Dementia is a progressive illness and current approaches are short term.

7. Commissioning for Dementia Care • There are 3 strands to commissioning • Strategic Planning • Outcomes and procurement • Demand and Performance • Currently we are not seeing those strands in place within Bucks. It is likely Bucks is at the start of developing their strategy. The Care Home Audit sent out 6 Jan 2011 sought to establish the prevalence of dementia.

8. Strategic Planning • The base line strategy follows the National Dementia Strategy. First and foremost is the safety of the PWD in terms of meeting physical, mental and social needs. • The second part of this string is the effectiveness of a service. The Government want to use PROMs to measure effectiveness, alongside other clinical measures. In keeping with the official stance they want to see improvements in the PWD’s experience. • This experience cannot be held purely in the PWDs experience but must cover relatives, informal carers and formal carers. The major impacts of dementia in these groups are mental distress, guilt and feelings of loss.

9. Outcomes and Procurements • Based in the NDS this makes reference to Living Well with Dementia in Care Homes, and the reduced use of anti-psychotic medication. • There are no qualitative measures in place to recognise when such a state is achieved. We see a change from dependency states to outcomes achieved, but these measures are not robust. • At present there is no way of operating this strand of commissioning.

10. Demand and Performance • There are measures to rely upon in this area. • NICE (2009; Quality Standards) include: • Appropriate training for staff- (What is available?) • Personalised assessment with a named coordinator • People with Mental Capacity have the opportunity to make: Advanced statements, refusal of treatment, LPOA and Preferred priorities of Care • Physical symptoms and those that cause distress are analysed and interventions planned • EOL Care is planned through the GSF or LCP

11. Outcomes of Demand and Performance • Information is given to people to allow choice • Specialist care is provided to slow or even reverse the progression of incapacity. • Challenging behaviour is managed rather than drugged. • Needs are seen early and appropriately supported to achieve stability of co-morbidities

12. How will a Good Service benefit users and commissioners? • DH 2010: The level of resources should be proportionate to the value, complexity and risk. The higher the benefit, the higher the cost. • Local commissioners need to know the benefits and the value of our services

13. The Benefits • Reduced LOS in Hospital • Improved Hospital discharge • Prevention of re-admission and the avoidance of crises • Clarity of service purpose and expected outcomes. (Care Pathway) • Provision of risk management strategies for users and family • Ability to adapt and manage partnership working • Effective management of co-morbidities • The provision of an information service for the community

14. Key elements for Commissioners • A service provision that demonstrates: • A Reflective culture acting within client’s best interests • Integration with local clinical networks • Adaptability and capability to work within the new commissioning environment • Effective and consistent safeguarding procedures • Clear activity plans- Financial activity and care pathways • Cost effective support for vulnerable people

15. Quality Outcomes may include: • User experience strategies (DCM) • Incidence of: • Pressure sores • EA to hospital • Falls • UTIs • Staff turn over and agency use • Clinical errors (i.e Medicine errors) • Achievement of agreed goals

16. The Cost of Dementia care • Costs being driven down as demand increases • Our locality offer care at a range of $650 to $1295 per week • PCTs are seeking to return OOC placements and will accept higher rates if there is a saving. • Very tight to gain reasonable price for movement from Residential to Nursing care • Costs nationwide vary immensely. • We need a formula to identify the actual cost of care in keeping with expected outcomes.