Last month, the Care Quality Commission warned that health and social care staff were struggling to adequately meet the needs of people with dementia. As a result, care home residents with dementia faced disproportionate numbers of avoidable hospital admissions and longer stays, and were more likely to die in hospital than other patients.
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Council social care commissioners, and their health equivalents in the new clinical commissioning groups (CCGs), are tasked with turning round this situation at a time of shrinking resources and when the population of people with the disease is rising. To help them, the National Institute for Health and Care Excellence (Nice) today published guidance on commissioning for dementia care, accompanied by a tool to help commissioners measure the quality of services in their area against national standards.
The guidance was drawn up with an advisory group of health and social care leaders and has been published alongside Nice’s new quality standard on dementia, setting out what service users and families should expect from services.
The advisory group for the guide identified a lack of joint working across health and social care as “the biggest barrier to the delivery of high-quality care for people with dementia”, so integrating commissioning is a key element of the guidance.
Single commissioning plan ‘preferable’ to separate health and social care plans
The guidance says that, at a minimum, health and social care commissioning plans should be “complementary”; but it says it is “preferable” to have a single commissioning plan spanning the two services, and based on a joint strategic needs assessment identifying the current and future needs of people with dementia and their carers.
It is less definitive on whether CCGs and councils should have a single commissioning team for dementia or not, though it suggests this would be a good idea. It cites the example of Walsall, where a joint commissioner for health and social care has been able to help integrate care provision.
To enable providers and professionals to sign up to the same vision for dementia care, it suggests commissioning a “dementia care network”, bringing together all providers of specialist and universal services for people with dementia. Members of the network would be expected to work together to respond to design care pathways to meet the diversity of needs presented by people with dementia.
The network should be underpinned by a multi-agency dementia partnership, encompassing relevant providers, commissioners, safeguarding agencies and families.
Targeted case finding for early identification of dementia
In line with government priorities, the guidance emphasises the importance of early identification and diagnosis of dementia. One strategy for this that it proposes is “targeted case finding” to help identify people with the condition in high-risk groups.
This could include having systems for GPs to regularly review people in residential care for dementia or commissioning specialist in-reach services, for example from older people’s mental health teams, to go into care homes to improve staff skills in identifying dementia.
It also says commissioners should ensure GPs hold a register of people with mild cognitive impairment to ensure they are regularly reviewed for dementia. It also advocates setting a target for improving diagnosis rates.
Specialist diagnosis services ‘should be accredited’
The Nice quality standard states everyone with suspected dementia should be referred to specialist memory assessment services. The advisory group for the commissioning guide stated these could take a variety of forms and could encompass more than one provider.
But it stresses that the services should be accredited by the Royal College of Psychiatrists’ Memory Services National Accreditation Programme, or be working towards this.
Care co-ordinators for all
The guidance states that commissioners should ensure that all people newly diagnosed with dementia receive an assessment of their social care, and other needs, and that any carers receive a carer’s assessment. This should lead to a personalised care plan, encompassing health and social care needs, that identifies a named care co-ordinators for all people with a diagnosis.
It says commissioners should ensure “a robust model of care co-ordination” and suggests this role could be undertaken by a range of different professionals: GPs, dementia nurse specialists, geriatricians or dementia support workers. Social workers are not named explicitly.
Improving end-of-life care and behavioural support
The guidance said many people with dementia’s experience of end-of-life care was poor and characterised by unnecessary hospital admissions and bad pain management; it also warned that it was harder to identify when people with dementia required end-of-life care, compared with other conditions, due to the slow progression of the disease. The guidance makes a number of suggestions to improve this including identifying triggers with providers for when people with dementia should be referred to end-of-life care registers, and enlisting GPs and nurse specialists to work with care homes to help improve their response to residents’ palliative care needs.
The advisory group agreed that interventions to help people manage the behavioural and psychological symptoms of dementia were lacking in many areas, which could lead to the over-prescription of antipsychotic drugs to manage behaviour that challenges services.
It said commissioners should take action to reduce the prescription of antipsychotic drugs by commissioning a range of therapies and investing in life story work to help increase understanding of people’s histories and preferences.