1. MIDLOTHIAN COMMUNITY CARE PARTNERSHIP Dementia Demonstrator Site Jane Fairnie Planning Officer

2. Midlothian Midlothian is the second smallest local authority area in Scotland. It adjoins Edinburgh’s southern boundary, and is framed by the Pentland Hills in the west and the Moorfoot Hills of the Scottish Borders in the south. Most of Midlothian’s population, of around 80,000, resides in or around the main towns of Penicuik, Bonnyrigg, Loanhead, Dalkeith, Newtongrange and Gorebridge. The southern half of the authority is still predominantly rural, with a small population spread between a number of villages and farm settlements.

3. Midlothian The General Registers of Scotland predicts that the population of Midlothian will decrease by approximately 1,256 people by the year 2020. This estimate, however, does not take into account planned new housing developments The 60+ age groups are growing in comparison with the rest of the population. Midlothian will soon have more pensioners than children In 2009/10 – 588 people with diagnosis of dementia on QOF register In 2010/11 – this had risen to 637

4.  The project will seek through a whole systems approach, to develop community based services which reduce reliance on long stay care homes and continuing care beds and minimise admissions to acute hospital OBJECTIVES OF THE MIDLOTHIAN PROJECT

5.  Developing a better understanding of users’ experience of services through IRF mapping and through user/carer consultation to influence the redesign  Delivering stronger integrated care pathways for people with dementia to streamline and speed up access to services.  Promoting a joint approach to the allocation of resources between NHSL and the Council to support people with dementia more effectively  Promoting “Shifting the Balance of Care” for people with dementia through stronger integrated working across health, social work and the wider community OBJECTIVES OF THE MIDLOTHIAN PROJECT

6.  Service mapping in all services across Health, Social Work and Third Sector completed using SWOT analysis to audit services against the Standards of Care for Dementia in Scotland, and data now being collated  Examples of initial findings show gaps in areas of communication with people who live with dementia – staff don’t have knowledge of, or access to specialist communication tools, knowledge of legal framework such as POA, guardianship etc, knowledge of advocacy services, need for meaningful activity and involving carers in staff training  Examples of excellence found in end of life care, carer support, promoting independence and treating people with dignity and respect Progress to date

7.  Family Group Conferencing identified at a Stakeholders Event as a post-diagnostic support tool  Now being taken forward as a project  Currently in research phase  Visit planned early October to Hampshire’s “Daybreak” project  Based on the principle of “Family Solutions to Family Problems” where families and close support networks take ownership of supporting the person with dementia thus reducing reliance and dependence on rigid and inflexible formal supports Progress to date

8.  Workforce Development  Staff questionnaire currently out to all care and support staff in Midlothian  Aim is to benchmark current qualification, knowledge, skills and understanding prior to rolling out any awareness raising and training programmes to measure the impact of that training – links to Promoting Excellence Framework  Funding roll out of training programme for Care at Home staff across Midlothian in all sectors through Stirling University and establishing Dementia Champions Progress to date

9.  GP engagement  GP survey completed – positive suggestions for service redesign locally  GP sign-up to sharing QOF data for IRF mapping to identify patient pathways Progress to date

10.  Narrative research into the lived experience of dementia from both the individual and the carer perspective  Being undertaken by Queen Margaret University with the Researcher now in post  6 month project involving semi-structured interviews and focus groups to explore how individuals make sense of experiences related to their condition, their attitudes toward those experiences, what meanings the events hold for them and how these meanings are created in the light of contextual and cultural factors  This research will enable the project team to further identify service gaps and barriers. Progress to date

11.  User/Carer survey being sent out in January 2012  To compliment the Narrative research  Using a Talking Points model  To identify what works well for people who live with dementia and their carers and what has made their journey more difficult Progress to date

12.  IRF data mapping  Part of the Lothian IRF Project  Data from 08/09, 09/10 and 10/11 will be used to map dementia pathways down to individual GP practice level  Use of Caretrak software to analyse data  All data will be ready for analysis by end 2011  IRF data will be used to measure cost savings at the end of the project as part of the evaluation process Progress to date

13.  Service redesign will be predicated upon what people with dementia and their carers tell us will help make their journey smoother  Early indications from Stakeholder consultation suggest this may include  A single multi-disciplinary assessment, treatment and care management service  A Midlothian dementia toolkit to include a multi- disciplinary assessment and single care plan  A responsive and flexible dementia-friendly Home Care service which is not bound by rigid time slots  A local Dementia Working Group for Midlothian people The Future

14. Further details on this work from Jane Fairnie Jane.Fairnie@midlothian.gov.ukJane.Fairnie@midlothian.gov.uk Janice Flockhart Janice.Flockhart@nhslothian.scot.nhs.ukJanice.Flockhart@nhslothian.scot.nhs.uk Peter Haughey Peter.Haughey@midlothian.gov.ukPeter.Haughey@midlothian.gov.uk Workshops: SWOT Analysis – auditing against the Standards Family Group Conferencing – post diagnostic support Find out more