Joint commissioning by PCTs and councils key for dementia services

Joint commissioning by PCTs and councils is key to meeting the demands of increasing dementia but its benefits in terms of savings and outcomes are yet to be fully felt, writes Sally Gillen

Dementia is arguably the biggest challenge facing health and social care in England, and undoubtedly effective joint commissioning is crucial to tackling it.

With age being the condition’s main risk factor, the number of people with dementia is set to rise from about 575,000 to almost 800,000 by 2021.

But it is already placing significant strains on councils and primary care trusts.

Two-thirds of care home residents have dementia, with 70% of the cost borne by the state. An estimated 60% of acute hospital beds are taken up by older people, 40% of whom may have dementia.

In a report last year, the National Audit Office (NAO) said dementia was costing the NHS £1.17bn and adult social services £2.13bn a year, while also placing a £5.2bn informal care burden on families.

However, the evidence suggests primary care trusts (PCTs) and councils are struggling to get it right for people with dementia, their carers or taxpayers.

Efficient dementia service

Andrew Chidgey, head of policy and campaigns at the Alzheimer’s Society, says: “At the moment we do not have a health and social care system that is set up to recognise dementia. There needs to be clear ownership of dementia and structures that allow people to be treated quickly and efficiently.”

For instance, while early diagnosis can help delay progression of the disease, prevent emergency hospital admissions and delay entry to residential care, the NAO found just one-third to half of people with dementia received a diagnosis at all.

The NAO also found less than a third of community mental health teams for older people, which are supposed to take responsibility for dementia care, had joint health and social care funding arrangements. These issues prompted the Department of Health to develop a national dementia strategy for England, due for publication this month.

One of the recommendations made in a consultation paper in June was for PCTs and councils to establish joint commissioning strategies that would feed into the operational plans and budget cycles of both organisations. The importance of joint commissioning of dementia care was stressed in November 2005 in Everybody’s business, a guide to developing integrated older people’s mental health services produced by the Care Services Improvement Partnership (see box below).

However, Jenny Owen, vice-president of the Association of Directors of Adult Social Services and joint lead on the national dementia strategy, says there is little national data available about dementia services and what progress is being made nationally towards joint commissioning is unknown.

Joint investments

Councils and PCTs can both save money and improve outcomes by investing jointly in dementia services. But calculating savings accurately is difficult and there may be reluctance on one side or the other to contribute money to a joint service, particularly when there may be a lack of evidence.

Professor Jill Manthorpe, director of the social care workforce research unit at King’s College London, says: “Clearly everyone hopes for a mutually beneficial outcome, financially and in terms of well-being, but we are not very advanced in costing whole systems.”

She says that there are difficulties for commissioners in investing in new types of services, adding that PCTs and councils have “long-standing commitments to service provision, for example block contracts”.

Dementia care guidelines

A costings report produced by the Social Care Institute for Excellence and the National Institute for Health and Clinical Excellence for their 2006 guideline for dementia care said joint working and co-ordinated delivery of health and social services could initially incur extra costs. However, over time it would lead to savings through withdrawal of investment from ineffective provision and a reduction in duplication through single assessment points and records.

This idea of investing jointly to save money across the whole system is embodied in a key proposal in the dementia strategy consultation – an early diagnosis and intervention service for all people with dementia.

It proposed a £220m annual investment in multi-disciplinary memory services, to handle diagnosis and immediate care needs, and extra capacity in community mental health teams and adult social care, to handle referrals from memory services.

The consultation said there was “good evidence” this would lead to reductions in residential care admissions for people with dementia from the fourth year onwards.

Reductions of 10% a year, coupled with modest improvements in quality of life would make the service cost effective over a 10-year period, it argued.

Long-term perspective

This, of course, requires councils and PCTs to take a long-term perspective together. And while it was suggested there could be substantial savings for the NHS, for instance in reduced emergency hospital admissions, these were not costed in the consultation paper, unlike the savings for social care in reduced care home use.

The model derives from the experience of Croydon Council and Croydon Primary Care Trust, which have jointly commissioned a memory service since 2002, staffed by a multi-disciplinary team.

John Haseler (pictured right), assistant director for mental health and substance misuse commissioning at the PCT, says the referral rate has increased year-on-year – with more than 400 expected during 2008-9 – and says “capacity will need to increase by over half to meet the rising demand”.

Clinician driven

Haseler says the drive for the service came from clinicians, not commissioners, and it addressed a previous lack of community-based support for people with dementia. “Maybe other commissioners are faced with having to decommission in order to develop this sort of service,” he says.

He also says the service has not required pooled budgets across the PCT and council, adding: “We seem to have done well on the integration of services without the need to pool our finances.”

Haseler adds that it is difficult to estimate financial savings.

But the council’s director of adult services, Hannah Miller, says there is no denying that the memory service has saved money.

Both are clear that outcomes have also improved. Haseler says: “There are health gains and people who use the service are telling us that their quality of life has improved.”

Miller adds: “We recently had a carers day and several people spoke about how much support they had I was reminded that it is not the same for others around the country.”

The DH will hope that examples such as Croydon’s will spur PCTs and councils around the country to jointly commission high-quality and efficient dementia care.

Other policies

However, councils and PCTs also face separate policy drivers from the DH. For councils, there is the Putting People First agenda to personalise care, and for PCTs the world class commissioning programme, which seeks to boost efficiency, health outcomes and quality of care across the NHS. Accompanying the latter is the implementation of health minister Lord Darzi’s NHS next steps review, whose goals include reducing health inequalities, improving access to primary and community care and personalising health services.

Some question whether the demands on PCTs and councils are sufficiently compatible, including for people with dementia. But Putting People First is designed to benefit all client groups, including people with dementia and their carers. To ensure that dementia is given sufficient priority in the world class commissioning programme, it will include a specific guideline on dementia care. And as part of the Darzi review, some strategic health authorities have developed care pathways specifically for dementia.

Chidgey adds: “If [councils and PCTs] want to deliver personalisation and Darzi, they cannot do it without getting services right for people with dementia.”

References

• National Audit Office, Improving services and support for people with dementia 
• National dementia strategy consultation
• Social Care Institute for Excellence/ National Institute for Health and Clinical Excellence, Supporting people with dementia and their carers