1. Cornwall and Isles of Scilly Memory Assessment Service Julie Green, Commissioning Manager, Older People and People with Long Term Conditions Angie Turner Project Lead Cornwall Partnership Trust 17 th November 2009

2. Commissioning Dementia Assessment and Diagnosis Services

3. Local Context Dementia a PCT/Council commissioning priority as determined by local needs analysis and epidemiological challenges before the National Dementia Strategy! Epidemiological Analysis: 8,213 vs Aug 08 Dementia Registers: 2,645 Tools available to Commissioners: –NICE Guidelines - Evidence-Based Instruction Manual (Implementation Guidance very helpful) –World Class Commissioning – Increasing numbers of people receiving a diagnosis set as World Class Commissioning Outcome Focus on market segmentation and market management, with expert advice from SHA Commissioned consultancy AT Kearney Emphasis on involving patients and carers

4. Beyond Older Peoples Mental Health and towards integrated pathways for PEOPLE with dementia

5. Commissioning integrated pathways rather than organisations Prevention Awareness Recognition Assessment Diagnosis Case Mgmt Unscheduled End of Life Good quality care tailored to dementia Simple pathways and overlapping services Tiered Menu of Interventions

6. Drivers for Change (Old Provision) No service specification Bundled in with wide range of Older Peoples Mental Health Services – i.e. the mix of functional and organic Unclear provision for younger people Established provision for people with learning disabilities, but not integrated Wide variation across county (access, waits and quality) Some Memory Clinics Little carer or service user involvement in design, delivery and review of services Lack of integration with primary care and no flows of communication back to Dementia Registers – absolutely essential

7. Developing a Service Specification Decision made to develop a service specification and ask existing specialist provider, Cornwall Partnership NHS Trust to reconfigure to meet standards and expectations set To be achieved within existing resources – a reframing and standardisation of existing service Would initially remain as a block contract, but with a view to developing an activity based tariff (most straightforward part of pathway to do this) Available to everyone with suspected dementia, irrespective of age, ethnic origin or social status, including people with Learning Disabilities The service would offer a choice of venues for assessment, including Memory Clinics, home assessments and assessments in care homes. Key principle – organise around GP practices as early on identified anticipated prevalence and numbers of people on register Would be required to work closely with GPs and upskill primary care to increase the amount of screening, assessment diagnosis that could eg take place here

8. Calculating Referral Demand For service planning, need to know how many referrals to expect a year Limited historical information – new referrals for dementia not previously recorded (remember just OPMH activity and included eg crisis referrals for functionals) Advice from local service was approximately 2000 assessments a year Non-learning disability referrals set as 23% of prevalence (i.e. 1864) assessments a year Learning Disability referrals set as 2% of prevalence (164 assessments a year)

9. Calculating Demand for Memory Clinics Clinics vs Home Assessments Need to balance the need for increasing throughput with realities of being a rural area with limited transport infrastructure Some concerns that clinic assessment lower quality than home assessment – but difficult to evidence. Decided to set expectation that 40% of total referrals could be seen in Memory Clinic, collect evidence for first year and then adjust if necessary

10. Determining Location of Memory Clinics Shift from being organised around the convenience of organisational bases and professionals to the convenience of patients and carers! Major Towns (Truro, Falmouth, Liskeard, Saltash, St.Austell, Newquay, Wadebridge, Bude, Bodmin, Camborne, Helston, Penzance, Redruth, Hayle, St.Ives, Looe, Callington) Easily accessible venues – close to public transport Non-stigmatising – preferably not associated with Mental Health Quality Check – would be vetted and signed off by panel of service users and carers Specifying locations very popular with patients, carers, the public, council and GPs and the media

11. Determining Frequency of Memory Clinics Less then 10 potential annual assessments in Memory Clinic = No Memory Clinic 11 - 50 potential annual assessments in Memory Clinic = 0.5 Day Memory Clinic every two weeks 51 - 94 potential annual assessments in Memory Clinic = 0.5 Day Memory Clinic every week 95 - 149 potential annual assessments in Memory Clinic = 1 day Memory Clinic a week 150 potential annual assessments in Memory Clinic = 1.5 day Memory Clinic a week

12. Other Quality Standards -Enable self-referral for those who do not want to access GP first -Referral to appointment target wait of 20 days -Appointment to Diagnosis target wait 30 days - Pre-counselling (compare genetic counselling) – to evidence informed choice; -Post diagnosis counselling – working through and beyond the diagnosis. Emphasis that there is rewarding and meaningful life after diagnosis, this is not a death sentence. -Standard information pack (approved by panel of patients and carers) -Everyone assigned a key-worker (Case Manager), linked to GP practice to support patient from diagnosis until end of life (Newquay model) -Patient / Carer Satisfaction results collated and published on service website -Requirement on new provider to deliver education, training and support to primary care

13. Public Engagement -Draft service specification sent out to wide range of stakeholders for feedback -Summarised version sent to every member of Alzheimers Society in Cornwall for feedback – received some very encouraging hand-written letters of support and telephone calls.

14. Implementation and Monitoring -Action plan for delivery set out in service specification 25% of Memory Clinics are established by July 09 75% of Memory Clinics are established by Dec 09 100% of Memory Clinics are established by Apr 10 Additional Monthly Commissioner/Provider performance meetings established to monitor progress and delivery Information reports agreed (Section 20 of Spec)

15. Next steps for Commissioners Ensuring implementation Agreeing quality standards when patients diagnosed e.g. in Acute hospital (different provider) Unlocking the finances – once established, should have sufficient data to determine cost of average diagnosis, opening up possibilities of moving to a cost per case activity contract Developing a service specification for Case Management (i.e. post diagnosis)

16. The Providers Journey Where we started The journey and who we met along the way Some of Road Blocks Where we have got to Where we go next

17. Context Draft Commissioning strategy January 2009 based NICE guidelines Debate/Discussion. Pressure on Commissioner - Provider relationship March 09 Project Lead role Inclusive style to facilitate service change and delivery

18. Where we started Each team offering memory assessment and diagnosis service Service delivered in different ways across the county Different resource allocation No standardisation of assessment Specific details not captured on data system

19. The Journey Engagement with key individuals Working on strengths and what could be achieved Project Management Group Broadening out involvement- Task groups Standardise services

20. Task groups Right people Right Place Venues Assessment and Diagnosis Pathway Referral Protocol Scans Drop in/Self Referral Performance data Booking system Service Information Post Diagnosis Counselling Training Plan

21. Outcomes/Learning from task groups Care Pathway Enhancing the Commissioning Specification Venues and Partnership Partnership Supporting workforce change and development Data collection

22. Where have we got to 18 out 20 clinics up and running rest scheduled within next 6 weeks Standardised practice across the services Information on service on web site, service leaflets. information packs Process for feedback from individuals and carers Raised Profile of Early Detection and Diagnosis Increased reported morale of staff with focus on specialist skills development Increase in positive attitudes around Partnership working

23. Road Ahead The future-Case management Capacity planning Audit and research Robust data collection and reporting

24. Getting it Right For People Good End of Life Care Good Acute Care Support for Carers Good Quality of Care in Care Homes Good early Diagnosis, memory clinics and support Intermediate Care/Rapid response/re- enablement etc Support at home Housing & Support and Telecare Information and Advice to stay Independent

25. Contact Details Angie Turner Project Lead Cornwall Partnership Trust Tel: 01209 881803/1876 Email: angie.turner@cpt.cornwall.nhs.uk Julie Green Julie Green, Commissioning Manager, Older People and People with Long Term Conditions Tel: 01209 886585 Email: julie.green@ciospct.cornwall.nhs.uk www.dhcarenetworks.org.uk/dementia/topics/browse/commissioning/