Intelligent Targets: Dementia (NHS Wales) Professor Bob Woods Bangor University

National Dementia Plan for Wales October 2008: Health Minister, Edwina Hart, commissioned a ‘new group of health professionals and experts’ to produce a Plan October 2008: Health Minister, Edwina Hart, commissioned a ‘new group of health professionals and experts’ to produce a Plan To ‘provide us with the opportunity to address current dementia services and look at how we can effectively deal with the projected growth in the number of people suffering with dementia over the next 20 years.’ To ‘provide us with the opportunity to address current dementia services and look at how we can effectively deal with the projected growth in the number of people suffering with dementia over the next 20 years.’

National Dementia Plan for Wales Starting point: conclusions from Charles Twining’s scoping review Starting point: conclusions from Charles Twining’s scoping review Wales has enough strategies (e.g. NSF, 2006) Wales has enough strategies (e.g. NSF, 2006) What is needed is an Action Plan What is needed is an Action Plan Group worked from December 2008 – April 2009 Group worked from December 2008 – April 2009 Chaired by Ian Thomas (Alzheimer’s Society) Chaired by Ian Thomas (Alzheimer’s Society)

Draft National Dementia Action Plan Issued for consultation summer 2009 Issued for consultation summer 2009 ‘Dementia supportive communities’ ‘Dementia supportive communities’ – Strengthening individuals – Strengthening communities – Improving infrastructure and access to services for all – Making structural changes to economic, cultural and environmental conditions

Draft National Dementia Action Plan - Consultation Consultation included several workshops with professionals and sessions with people with dementia and carers Consultation included several workshops with professionals and sessions with people with dementia and carers Consultation closed September 2009 Consultation closed September 2009 Consultation responses published on WAG web-site – 400 pages Consultation responses published on WAG web-site – 400 pages Draft plan broadly welcomed, but seen by many as ‘aspirational’ or a ‘wish-list’ Draft plan broadly welcomed, but seen by many as ‘aspirational’ or a ‘wish-list’ Major gaps: Major gaps: Rural diversity Rural diversity Younger people with dementia Younger people with dementia Language preferences (including Welsh) Language preferences (including Welsh)

National Dementia Action Plan – phase 2 January 18 th 2010: Edwina Hart reconvened the task and finish group January 18 th 2010: Edwina Hart reconvened the task and finish group Presented with short-list of key priorities Presented with short-list of key priorities Workshop with wider group of stakeholders – Port Talbot, February 19 th 2010 Workshop with wider group of stakeholders – Port Talbot, February 19 th 2010 Instructed to come up with a SMART action plan by end of March 2010 Instructed to come up with a SMART action plan by end of March 2010 (Specific, Measurable, Achievable, Realistic, Time- bound) (Specific, Measurable, Achievable, Realistic, Time- bound)

Priority areas for action Improved service provision through better joint working across health, social care, the third sector and other agencies, including: Improved service provision through better joint working across health, social care, the third sector and other agencies, including: Older people CMHTs to be fully integrated across health and social care Older people CMHTs to be fully integrated across health and social care Improve quality of general hospital care Improve quality of general hospital care Reduce inappropriate use of anti-psychotics Reduce inappropriate use of anti-psychotics Improved early diagnosis and timely interventions Improved early diagnosis and timely interventions Improved access to better information and support for people with the illness and their carers Improved access to better information and support for people with the illness and their carers Improved training for those delivering care & greater awareness of need for advocacy Improved training for those delivering care & greater awareness of need for advocacy

Ministerial statement – May 11 th 2010 Focus must now be ‘on operational delivery and genuine meaningful service improvements’ Focus must now be ‘on operational delivery and genuine meaningful service improvements’ ‘Action plans’ from the 4 sub-groups published on the WAG web-site – unedited, unformatted, uncosted ‘Action plans’ from the 4 sub-groups published on the WAG web-site – unedited, unformatted, uncosted Implementation entrusted to the Mental Health Programme Board Implementation entrusted to the Mental Health Programme Board Intelligent targets seen as a core component of the plan Intelligent targets seen as a core component of the plan Bitter disappointment that no Action Plan as such would be published (yet) Bitter disappointment that no Action Plan as such would be published (yet) Programme Board has established Dementia Group, chaired by Rob Pickford (Director Social Services Wales), including chairs of the 4 sub-groups, to take forward implementation Programme Board has established Dementia Group, chaired by Rob Pickford (Director Social Services Wales), including chairs of the 4 sub-groups, to take forward implementation

Additional funds for dementia care – 13 th July 2010 £1.5 million per annum £1.5 million per annum Develop services for younger people with dementia Develop services for younger people with dementia ‘An additional dedicated dementia clinical post in every older person's community mental health team across Wales, to provide advice and support to those diagnosed with dementia and also provide direct support to memory clinics, dementia training and awareness-raising for staff’ ‘An additional dedicated dementia clinical post in every older person's community mental health team across Wales, to provide advice and support to those diagnosed with dementia and also provide direct support to memory clinics, dementia training and awareness-raising for staff’ Plans to be submitted by end of October Plans to be submitted by end of October Advisory workshop 6 th October 2010 Advisory workshop 6 th October 2010

The Dementia Plan and Intelligent Targets for the NHS in Wales Early in 2009 a number of areas were identified where a focus on improvement in the NHS was thought important. Early in 2009 a number of areas were identified where a focus on improvement in the NHS was thought important. Mental health domain led by Mary Burrows included depression, eating disorders, first episode psychosis as well as dementia Mental health domain led by Mary Burrows included depression, eating disorders, first episode psychosis as well as dementia Dementia Plan Task & Finish Group collaborated with this process to ensure consistency Dementia Plan Task & Finish Group collaborated with this process to ensure consistency How can we best improve NHS services for people with dementia in Wales with targets that will make a real difference?? How can we best improve NHS services for people with dementia in Wales with targets that will make a real difference?? Intelligent targets are highly congruent with the 4 priority action plans – main additional area in plans is integration of health and social care Intelligent targets are highly congruent with the 4 priority action plans – main additional area in plans is integration of health and social care

Developing the dementia targets Possible domains and care bundles identified from NICE-SCIE guidelines and other relevant documents Possible domains and care bundles identified from NICE-SCIE guidelines and other relevant documents Evidence-based Evidence-based Consultation with people with dementia and carers: Consultation with people with dementia and carers: Agreed domains Agreed domains Prioritised actions from the ‘care bundle’ for each domain Prioritised actions from the ‘care bundle’ for each domain Consultation with practitioners & managers Consultation with practitioners & managers What are the key areas for (NHS) improvement? What are the key areas for (NHS) improvement? Draft measures for each domain Draft measures for each domain

Selected domains 1) making and sharing the diagnosis - empowerment 1) making and sharing the diagnosis - empowerment 2) dementia in the general hospital 2) dementia in the general hospital Counting the cost – Alzheimer’s Society Nov 2009 – dementia increases length of stay Counting the cost – Alzheimer’s Society Nov 2009 – dementia increases length of stay POTENTIAL FOR COST SAVING AND BETTER QUALITY POTENTIAL FOR COST SAVING AND BETTER QUALITY 3) use of anti-psychotics 3) use of anti-psychotics Department of Health report Dec deaths, 1620 CVAs per annum Department of Health report Dec deaths, 1620 CVAs per annum Reduce use by a third in England Reduce use by a third in England POTENTIAL FOR COST SAVING AND BETTER QUALITY POTENTIAL FOR COST SAVING AND BETTER QUALITY 4) support for care-givers – high levels of distress, increased mortality 4) support for care-givers – high levels of distress, increased mortality 5) improving quality of care in NHS in-patient care (and in care homes) – evident risk of harm 5) improving quality of care in NHS in-patient care (and in care homes) – evident risk of harm Training as an over-arching theme Training as an over-arching theme

Targets and measures to be reported to Health Boards - 1 Target One: Memory Assessment Services - First point of contact – reduce time between onset of symptoms & diagnosis being communicated Target One: Memory Assessment Services - First point of contact – reduce time between onset of symptoms & diagnosis being communicated Median time from referral by GP, social worker or other primary care worker to feedback interview. Median time from referral by GP, social worker or other primary care worker to feedback interview. Target Two: General Hospitals - Improved quality of general hospital care for people with dementia and reduced length of stay Target Two: General Hospitals - Improved quality of general hospital care for people with dementia and reduced length of stay Number of patients following agreed dementia care pathway (as percentage of at risk group i.e. over 65s) Number of patients following agreed dementia care pathway (as percentage of at risk group i.e. over 65s) Relatives’ satisfaction with care survey Relatives’ satisfaction with care survey

‘Care bundles’ In the dementia context these were not intended to be prescriptive or comprehensive In the dementia context these were not intended to be prescriptive or comprehensive They indicate the range of interventions that a person with dementia and his/her carer could expect to have considered with them and which would typically be documented They indicate the range of interventions that a person with dementia and his/her carer could expect to have considered with them and which would typically be documented They indicate the range of interventions needed to produce the desired process improvements, leading ultimately to improved outcomes They indicate the range of interventions needed to produce the desired process improvements, leading ultimately to improved outcomes

Targets and measures to be reported to Health Boards - 2 Target Three: Community mental health services for people with dementia (including those in care homes) - Reduced inappropriate use of anti- psychotic medications in accordance with NICE/SCIE guidelines. Target Three: Community mental health services for people with dementia (including those in care homes) - Reduced inappropriate use of anti- psychotic medications in accordance with NICE/SCIE guidelines. Number of people with dementia prescribed anti- psychotic medication Number of people with dementia prescribed anti- psychotic medication Proportion of people with dementia who are on anti- psychotic medication where review within 3 months Proportion of people with dementia who are on anti- psychotic medication where review within 3 months Proportion of people with dementia who have been on anti-psychotic medication for >9 months Proportion of people with dementia who have been on anti-psychotic medication for >9 months

Targets and measures to be reported to Health Boards - 3 Target Four: Community mental health services for people with dementia (including those in care homes) - Improved support for care givers Target Four: Community mental health services for people with dementia (including those in care homes) - Improved support for care givers Number of carers participating in multi-component carer support programmes Number of carers participating in multi-component carer support programmes Proportion of care-plans for people with dementia supported at home by family carers which include detailed and specific arrangements for emergency and crisis support Proportion of care-plans for people with dementia supported at home by family carers which include detailed and specific arrangements for emergency and crisis support Number of carers receiving individual psychological therapy for depression and anxiety related to care-giving. Number of carers receiving individual psychological therapy for depression and anxiety related to care-giving. Target Five: NHS dementia inpatient units – Improved quality of care Target Five: NHS dementia inpatient units – Improved quality of care Results from observational audit Results from observational audit Relatives’ satisfaction with care survey Relatives’ satisfaction with care survey

What will happen? A ‘How to’ guide will be published later this year, detailing the targets, and with suggestions for assisting implementation A ‘How to’ guide will be published later this year, detailing the targets, and with suggestions for assisting implementation Will include two brief survey forms for relatives of people with dementia which have been piloted with good response rates Will include two brief survey forms for relatives of people with dementia which have been piloted with good response rates General hospital wards General hospital wards NHS mental health units NHS mental health units Aim is to help staff understand and respond to the perspectives of the relative and the person with dementia Aim is to help staff understand and respond to the perspectives of the relative and the person with dementia Leads from each health board will meet regularly to coordinate learning and actions Leads from each health board will meet regularly to coordinate learning and actions

The intelligent use of targets Use developmentally, to drive forward service improvement Use developmentally, to drive forward service improvement Don’t look for prescriptive targets or national solutions Don’t look for prescriptive targets or national solutions Ownership Ownership Joint working Joint working A tool – not the solution – aim for systemic change A tool – not the solution – aim for systemic change