These guidance documents published by NHS England and the Local Government Association set out how NHS leaders and organisations will operate with their partners in Integrated Care Systems (ICSs) from April 2022.

Integrated care systems (ICSs) are partnerships of health and care organisations that come together to plan and deliver joined-up services and to improve the health of people who live and work in their area.

They exist to achieve four aims:

• improve outcomes in population health and healthcare
• tackle inequalities in outcomes, experience and access
• enhance productivity and value for money
• help the NHS support broader social and economic development.

Thriving places: Guidance on the development of place-based partnerships as part of statutory integrated care systems

This co-produced NHS England and NHS Improvement and Local Government Association (LGA) document seeks to support all partner organisations in integrated care systems (ICSs) to collectively define their place-based partnership working, and to consider how they will evolve to support the transition to the new statutory ICS arrangements, anticipated from April 2022.

ICS implementation guidance on working with people and communities

The ICS Design Framework sets the expectation that partners in an integrated care system (ICS) should agree how to listen consistently to, and collectively act on, the experience and aspirations of local people and communities. This guidance sets out 10 principles for how integrated care boards (ICBs) can develop their approaches to working with people and communities, and the expectations.

ICS implementation guidance on effective clinical and care professional leadership

This guidance supports the development of distributed clinical and care professional leadership across integrated care systems (ICSs). It describes ‘what good looks like’ in this regard, based on an extensive engagement exercise involving over 2,000 clinical and care professional leaders from across the country, led by a multi-professional steering group.

ICS implementation guidance on partnerships with the voluntary, community and social enterprise sector

This guidance provides more detail on how to embed voluntary, community and social enterprise (VCSE) sector partnerships in ICSs, for health and care leaders from all organisations in ICSs that are developing partnerships across local government, health, housing, social care and the VCSE sector. The ICS Design Framework sets the expectation that integrated care board (ICB) governance and decision-making arrangements support close working with the VCSE sector as a strategic partner in shaping, improving and delivering services, and developing and delivering plans to tackle the wider determinants of health.

Interim guidance on the functions and governance of the integrated care board

This interim guide covers the expected governance requirements for integrated care boards as outlined in the Health and Care Bill and the Integrated care systems design framework.

HR framework for developing integrated care boards

The HR framework provides national policy ambition and practical support for NHS organisations affected by the proposed legislative changes as they develop and transition towards the new statutory integrated care boards.

Building strong integrated care systems everywhere: guidance on the ICS people function

This guidance builds on the priorities set out in the People Plan. It is intended to help NHS system leaders and their partners support their ‘one workforce’ by delivering key outcome-based people functions from April 2022.

Working together at scale: Guidance on Provider Collaboratives

The ICS Design Framework set an expectation that provider collaboratives will be a key component in enabling ICSs to deliver their core purpose. This guidance outlines minimum expectations for how providers should work together in provider collaboratives, offering principles to support local decision-making and suggesting the function and form that systems and providers may wish to consider.

Integrated Care Systems: Design framework

Guidance on the employment commitment: Supporting the development and transition towards statutory Integrated Care Systems

This report published by the Care Policy and Evaluation Centre at the London School of Economics and Political Science provides projections of the number of older people (aged 65 and over) living with dementia in the UK and the costs of healthcare, social care and unpaid care from 2019 to 2040.

Download Projections of Older People Living with Dementia and Costs of Dementia Care in the United Kingdom, 2019–2040

The report reveals that by 2040, while the number of people living with dementia in the UK is expected to nearly double (to 1.6 million), the cost of social care is expected to almost triple, increasing from £15.7 to £45.4 billion. It falls to people living with dementia and their families to pay the majority of these costs.

The research found that the number of people living with more advanced dementia will rise more rapidly than the number of people living with mild and moderate dementia. As such, people will have higher associated care needs and more people will need social care for longer, increasing average social care costs.

The study also estimates that families are providing £13.9 billion a year in unpaid care for people living with dementia. This is also projected to increase to £35.7 billion by 2040.

The total cost of dementia to the UK economy has risen to £34.7 billion and will continue to rise to £94.1 billion by 2040. This includes costs to the NHS, paid social care and unpaid care.

Rerefences

This resource aims to enable Clinical Commissioning Groups to achieve and maintain dementia diagnosis rate of at least two-thirds of the estimated number of people with dementia, and improve the quality of and access to post diagnostic care for people living with dementia and their carers.

Download the Dementia Commissioning know how guide

The know how guide contains usefull information and links to documents, case studies and tools to help to achieve commissioning ambitions.

The know how guide covers the dementia care pathway and advocates a systematic, standardised approach to investigating and enhancing the attributes and processes that positively impact effective commissioning of dementia care services.

After working through the document, commissioners should be able to identify and develop, or enhance, the abilities and processes that need to be in place in order to successfully deliver commissioning of high quality dementia care services including:

• Strategic and leadership qualities and abilities
• Awareness of current performance
• Collaborative working with service providers
• Use of appropriate levers and incentives
• Accuracy and use of data in monitoring and reporting
• Resources to address any gaps or improvements required
• Futureproofing knowhow

This tool to support commissioning dementia services will help CCGs and STPs to:

• Improve the Dementia Diagnosis Rate as a continuous process.
• Assist with the refinement of local diagnosis processes and the dementia care path- way to deliver in line with the Implementation guide and resource pack for dementia care and improve outcomes for patients and carers.
• Realise the national ambition to provide consistently good quality, evidence-based dementia care and support for patients and carers.

The Dementia Care Pathway: full implementation guidance, published by the National Collaborating Centre for Mental Health (NCCMH), sets out key commissioning and service development considerations in the delivery and quality of care and support for people living with dementia and their families and carers.

Download The dementia care pathway: full implementation guidance | Appendices and helpful guidance

The guidance outlines the pathway and associated benchmarks to support improvements in the delivery and quality of care and support, for people living with dementia and their families and carers. It sets out what good quality assessment, diagnosis and care looks like in relation to formal guidance, in addition to the views and expectations of people living with dementia and their carers.

The guidance accompanies and builds on NHS England’s shorter Implementation guide and resource pack for dementia care published in July 2017 and revisd in January 2018.

The guide has two clear requirements to enhance dementia care, through:

• increasing the number of people being diagnosed with dementia, and starting treatment, within six weeks from referral; and
• improving the quality of post-diagnostic treatment and support for people with dementia and their carers.

The appendices and helpful guidance includes a diagram of the full pathway, a summary of NICE recommended care for people along the Dementia Well Pathway, information on HEE’s Dementia Core Skills Education and Training Framework and on NHS England Dementia: Good Care Planning, guidance for recording dementia care pathway benchmarks in the MHSDS, recommendations for outcomes measurement and examples of services who are already providing high quality care and elements of the pathways and some helpful web-based resources.

This guide is supported by:

• Dementia coding resource outlines the minimum information that should be included in dementia care planning and offers a frame of reference and a view of the depth and breadth of the areas to address in dementia care planning.
• Good care planning guide for dementia
• RightCare dementia pathway scenario

This guide aims to set out the policy drivers and strategic context for transforming dementia care, and why it is of importance to commissioners, providers and sustainability and transformation partnerships (STPs) in supporting delivery of a number of objectives in the Department of Health’s Prime Minister’s challenge on dementia 2020, published February 2015, which complements the aims of the Five Year Forward View, published in October 2014.

Download Implementation guide and resource pack for dementia care

It provides local services with evidence on what works in dementia care, headline access and quality benchmarks to support a reduction in unwarranted variation and draws on a number of good practice case studies throughout. Its overarching aim is to ensure that people with dementia, and their carers, receive good care and support; that no one has to wait months for an assessment of dementia.

This guide is important, not only for the NHS but for people with dementia and their carers too. It demonstrates our commitment to improving the quality of dementia care across the whole country, building on improvements to date and ensuring that we can provide excellent care and support for those who need it.

This guidance was co-produced by a national expert reference group (ERG) comprising experts by experience, clinicians, service managers, commissioners, academics, people with dementia, carers and others. Local service design should be similarly co-produced to meet the needs of the local population.

The National Audit of Dementia (NAD) (care in general hospitals) measures the performance of general hospitals against criteria relating to care delivery which are known to impact upon people with dementia while in hospital. The third audit collected data between April and November 2016.

The National Audit of Dementia Criteria include policies and governance in the hospital that recognise and support the needs of people with dementia, elements of comprehensive assessment, involvement of carers, discharge planning, and identified changes to support needs during admission.

Download National Audit of Dementia – third report |Individual hospital reports | Tools and guidance documents used | Standards for the audit

The audit found that hospitals in England and Wales have made many positive changes aimed at making hospitals more “dementia-friendly”. Overall nearly 70% of carers rated care as excellent or very good, and 75% said that the person with dementia was definitely treated with respect by staff. Many more hospitals are providing dementia awareness training to all groups of staff, and 96% have a training framework for dementia care, up from 23% in the first round of audit in 2011. Nearly all hospitals (94%), have created dementia “champions” to lead change and support staff, following a recommendation made in Round 2. Staff however said they could not always access specialist support, especially out of hours.

Nineteen percent of staff surveyed said that patients with dementia had nutritional needs met only some of the time, and five percent said their needs were not met. Three quarters of staff (73%) said they could obtain food 24/7 for their patients. Food outside of regular mealtimes is necessary for people with dementia as many patients forget to eat or only eat little and often, because dementia has disrupted their sense of routine.

In the webinar below, Dr Oliver Corrado, Dr Beth Swanson and Chloe Hood from the National Audit team present the findings from the third audit.

Key recommendations from the report include:

1. The Chief Executive Officer should ensure that there is a dementia champion available to support staff 24 hrs per day, 7 days per week. This could be achieved through ensuring that people in roles such as Site Nurse Practitioners and Bed Managers have expertise in dementia care.
2. National Commissioners should propose a national programme aimed at embedding the collection, sharing and use of person centred information with a clear expectation this information will follow the patient between providers.
3. Chief Executive Officers and commissioning services should make sure when tendering for new catering contracts that access to finger foods and snacks 24 hours a day is included.
4. The Safeguarding Lead should ensure staff are trained in the Mental Capacity Act, including consent, appropriate use of best interests decision making, the use of Lasting Power of Attorney and Advance Decision Making. Training should cover supportive communication with family members/ carers on these topics.
5. The Medical Director should ensure that hospitals have robust mechanisms in place for assessing delirium including appropriate assessment on admission and discharge with full recording of results.

This guide is aimed at primary care and commissioners, particularly GPs, who provide care plan reviews. It is designed to help improve care planning in dementia by supporting a standardised approach, highlighting good practice, ensuring alignment with relevant crosscondition care plans and help to reduce local variation in the process.

Download Dementia: Good Care Planning – information for primary care and commissioners

Care planning is a priority for NHS England and plays a vital role in improving the quality of mental health and dementia services. NHS England is committed to:

• supporting the delivery of the recommendations in the ‘Prime Minister’s challenge on dementia 2020’ including improving the ‘quality of post- diagnosis treatment and support for people with dementia and their carers’; and
• leading ‘a step change in the NHS in preventing ill health and supporting people to live healthier lives’, a key priority in the NHS England Mandate.

Care planning is a crucial element in delivering improved care for all people living with dementia, and supporting their families and carers. This has been brought into sharp focus through the CCG Improvement and Assessment Framework which includes indicators for dementia diagnosis and post diagnostic support.

This document has been developed with input from a diverse range of people living with dementia, their carers and health and social care professionals, to offer a quality assurance framework to enable more effective care planning, personalised and responsive to needs and preferences.

There is an urgent need to ensure every person who has dementia has an individual care plan and to aim for, wherever possible, greater integration with support plans in other areas such as social services.

The information provided in this resource document highlights the key characteristics of a person-centred dementia care plan and is aimed at primary care and commissioners who provide care plan reviews as part of the Quality Outcomes Framework (QOF) incentive scheme in primary care.

Improved care planning in dementia services will be achieved by:

• supporting a standardised approach reducing unwarranted local variation in process or outcomes;
• promoting equality and tackling health inequalities;
• ensuring alignment with relevant cross condition care plans such as diabetes; and
• drawing on examples of good practice around the country.

This document covers:

• The components which constitute the minimum information to be included in a good care plan.
• Examples of dementia care plans that are already being used at a local level.
• Considerations for computer systems available in primary care to create a dementia care plan and make appropriate links to care plans for correlated conditions.

The Dementia Atlas is an interactive map that plots data about dementia care and support, allowing people to compare the quality of dementia care across the country.

The data is grouped in themes based on NHS England’s well dementia pathway which serves as a framework to ensure people with dementia have a better experience of health and social care support from diagnosis through to end of life.

Access the map at https://shapeatlas.net/dementia

The Dementia Atlas contains an ‘Indicators’ panel which holds a range of data organised by themes as follows:

Preventing well
People can reduce their risk of dementia by living healthier lives. The earlier healthy behaviours are adopted the more likely a person is to have more years free from Illness, disability and frailty.

Indicators

• Smoking prevalence
• Hypertension prevalence

Diagnosing well
How many people within your local area, have been diagnosed with dementia?

Indicators

• New patients with dementia who have had a blood test recorded
• Dementia prevalence: ages 65+
• Dementia prevalence: all ages

Supporting well
More care and support for people with dementia, their families and carers should be provided out of hospital within people’s local communities to avoid unnecessary emergency admissions.

Indicators

• People with dementia using inpatient hospital services
• Emergency admissions

Living well
We want every person diagnosed with dementia to receive meaningful care following their diagnosis. Find out how many dementia Friends are in your area and whether your community is Dementia Friendly.

Indicators

• Care reviewed in the last 12 months
• Dementia Friends
• Dementia Friendly Communities

Dying well
In England, approximately 480,000 people die each year. One in 10 of these people will have dementia. One in three people who die after the age of 65 have dementia. All health and care staff who support dying people must be capable and compassionate in treating people with dementia.

Indicators

• Mortality rate
• Death in usual place of residence

This integrated checklist, published by the London Strategic Clinical Networks, will help commissioners to commission services that provide excellent care to people with dementia in both specialist and non specialist care settings.

The overall aim of the checklist is to help ensure the particular needs of people with dementia are considered when commissioning services.

Download Commissioner checklist for dementia

This list of aims applies across all levels of care and within services both in primary and secondary care but the level of detail for each stated aim would depend on the service being commissioned and the local needs. When commissioning a service the particular diversity of the population being served should be a key consideration e.g. BME, LGBT etc.

For example, in a hospital the commissioner may specify specific dementia friendly environments such as signage, however, in domiciliary care where this is not possible, it might be that there needs to be a system in place to report any negative environmental factors such as loose rugs so that the person with dementia and their carer can be informed in an appropriate manner and then make an informed decision.