Bridging the health-social care gap: life as a joint commissioner for dementia

Integrating social care and health can often be all talk and no action as agencies struggle to see how they can overcome cultural, funding and bureaucratic differences to deliver integrated services successfully. But it is also vital, particularly for people with dementia and their families.

Step forward Walsall, recently highlighted as good practice in this regard in the National Institute for Health and Care Excellence’s guidance for commissioners on dementia.  In 2009, Walsall Council and NHS Walsall established a joint commissioning unit housing commissioners for unplanned care, mental health, dementia, learning disabilities and older people.

Michael Hurt, formerly an older people’s mental health nurse, is the joint commissioner for dementia, the first person to hold this post.

At the time of his appointment, partnership working in Walsall wasn’t as good as it could be, says Hurt, and it was crucial to turn this around if the national dementia strategy was to be implemented successfully locally. So, he set to work changing services.

Reshaping support

An integrated dementia pathway for the acute hospital and community services was developed by a multi-disciplinary team including representatives from the hospital, community health, commissioning, primary care and social care.

As part of the pathway, an older people’s mental health liaison team and two dementia support workers, provided by Age UK, has been established at the acute hospital to promote a change in care culture, improve outcomes and improve understanding of dementia.

This initiative has proved so successful that Hurt is about to tender for two dementia support workers for care homes. Walsall has two purpose-built dementia care homes and 22 care homes and four nursing homes with dementia beds. “Their role will be to audit all care homes on the quality of dementia care and understanding, and then work with them to address any issues that are highlighted.”

Using technology

Walsall has a new independent living centre in the town where service users can be assessed by occupational therapists and try out assistive technology to help keep them independent. “Through the centre we have bought 20 iPADs and have used memory apps for people with dementia. We will loan them to care homes and community groups and if anyone wants to have their own they can use their personal budget to buy one.”

Another major change takes place in about three months when the new memory assessment service replaces the existing memory clinic. “We found that some GPs were reluctant to refer to the clinic because for those whose early dementia wasn’t at a level to meet eligibility criteria for social services or specialist care from the community mental health team there was little post-diagnosis support.”

This will change under the new service. As well as a consultant psychiatrist, consultant psychologist and OT, the service will have four extra mental health nurses to cope with demand and six personal assistants. “The PAs will deal with the more practical, social care side of things such as helping someone apply for attendance allowance or helping them make adjustments at home to make it more dementia friendly.”

New services

Walsall also now has:

• seven dementia cafés to provide information, support and a social outlet for carers and people with dementia;
  
• dementia advisers based with Age UK in the town centre to offer telephone and face-to-face support to users, carers and providers of dementia care;
  
• a dementia support worker for hard-to-reach groups;
  
• a dementia support worker based within the memory assessment service to visit people post diagnosis to offer information, support and signposting to other services for ongoing support.

“Other than statutory services, such as mental health services for advanced dementia, we didn’t have any of these services before my post,” says Hurt. “These services have all come about because I can concentrate on one thing and can use health and social services funding to make it happen in a co-ordinated way.”

Hurt wants to involve the voluntary sector in initiatives wherever possible. “We have a pot of money in health used for quality initiatives so when I’ve seen voluntary organisations that either already have services for people with dementia, such as singing groups, or could expand their services to this group, for example luncheon clubs, I’ve told them that if they bid for that money I’ll support them. They are picket services for us to prevent crises.”

Not following the pack

Hurt is keen to do his own thing in Walsall and not just follow the pack. “We have decided not to sign up to the government’s national dementia declaration for England because if you don’t deliver what you promise there are no repercussions.”

One of the focuses of the declaration is making communities much more friendly to people with dementia. To achieve this, Walsall has launched a kitemark system for local businesses to show how dementia-friendly they are through dementia-awarenes training for staff.

“When staff are trained the business can display our kitemark symbol on the premises so shoppers know it is dementia friendly. We will then monitor quality with carers as mystery shoppers.”

Although not obstacles as such, there are still challenges when it comes to joint working, including the fact that Hurt does not have a pooled budget to draw upon.

“A pooled budget would be excellent and would make things much easier for me as I have to put together a business case for every initiative I want to follow through which is time-consuming.

“And I still have two masters – health and social care – which can be difficult. It can also be an issue with the council not having a purchaser provider split because the provider side of the council can go off and do its own thing which can cause friction occasionally because dementia crosses everyone’s pathway.

“But it’s certainly much easier being a joint commissioner.”

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