Build capacity and support in the community
Questions to consider
- what do people with dementia, and their carers/families need, to live well?
- how can the needs of people living with dementia be better understood, and ‘mainstreamed’?
- what are the commissioning opportunities?
- what is the role of the GP and primary health care team?
DRIVER: Local strategic leadership
| Actions |
Resources |
Examples |
| Engage with local authority public health, and Health and Wellbeing Boards to review prevalence of dementia and trajectories for increase. Consider implications of this changing profile, over time. Undertake a needs assessment for the current and future population with dementia.
Ensure that the needs of vulnerable older adults are reflected in local planning strategies (supported housing; transport; health; social care, residential and nursing care; carers’ strategies; carers’ services). |
|
|
| Promote dementia friendly communities to tackle stigma, raise awareness, and promote opportunities for people living with dementia to live well. |
|
- Bristol as a Dementia Friendly City
This project aims to move Bristol towards becoming a ‘dementia-friendly city’ in which people with dementia can enjoy the same opportunities to take part in a social life, live independently and engage in everyday activity as other people, without fear of stigma or rejection. Read more »
- Dementia Action Alliance
The Dementia Action Alliance brings together organisations across England committed to transforming the lives of people with dementia and their carers. Read more »
- Dementia Health Integration Team Bristol and South Gloucestershire
The Dementia Health Integration Team (HIT) is a team of professionals who are all working together to transform care for dementia patients across Bristol and South Gloucestershire through comprehensive research, integrating and improving care services, and by creating dementia-friendly communities. Read more »
- Dementia Resource Suite
The Dementia Resource Suite contains tools and resources developed by pupils and teachers as part of an intergenerational project, to create dementia friendly communities in 22 pioneer schools across England in 2012-13. Read more »
- Developing a more Dementia Friendly Hampshire
The project aims to establish sustainable dementia friendly communities across the county of Hampshire, reaching as full a range of different communities as possible. Read more »
|
DRIVER: Appropriate treatment, care and support post-diagnosis
| Actions |
Resources |
Examples |
With stakeholders, review local strategies and care pathway(s) to identify range of support required at different stages and steps, and inform local strategies. For example,
- targeted screening for dementia
- information and guidance
- GP/Primary Care liaison and support
- education and training for carers
- flexible respite
- support and care at home, including night sitting
- case management/key working
- advocacy
- telephone contact 24/7
- specialist advice and interventions
- dementia care in hospital (acute and community hospitals)
- workforce development
|
|
|
DRIVER: Recognition and support in primary care
| Actions |
Resources |
Examples |
| Ensure effective training is in place for GPs and primary health care teams to ensure they have the competences required to recognise memory problems; undertake a basic dementia screen; make a diagnosis of dementia (moderate-severe stage); and refer to specialist memory assessment services where indicated. |
|
- Closer to home memory assessment: reaching out to rural communities in Buckinghamshire
This project aims to adopt the Gnosall primary care based memory assessment approach to improve dementia diagnosis in harder to reach communities in Buckinghamshire. Read more »
- Dementia diagnosis and management: a narrative review of changing practice
Through the EVIDEM project, Professor Steve Iliffe and colleagues, reviewed studies of interventions to improve GPs performance in the early detection and management of dementia. Interventions proved more successful when tailored to the learning needs of the GPs and developed with them. Read more »
- Devon dementia diagnosis action plan
This action plan outlines work underway to achieve improved, responsive and quality services for people with dementia and their carers across Devon. Key areas include: a GP clinical lead for dementia; a localised Map of Medicine; a memory assessment pathway; a GP education programme. Read more »
- Gloucestershire dementia strategy
The Gloucestershire dementia strategy recognises the pivotal role of primary care staff, and GPs in particular, in diagnosing dementia and in subsequently co-ordinating care across a range of services. Read more »
- GP dementia fellowship posts
Severn Deanery has recruited five GP Dementia Fellows to work with local practices to develop understanding about, treatment and care for people living with dementia. Read more »
- Greenwich Advanced Dementia Service
The Greenwich Advanced Dementia Service is helping people in the borough remain in their own homes for longer by supporting carers to increase their resilience. Read more »
- Oxleas Advanced Dementia Service: Supporting carers and building resilience
This case study, published by The King’s Fund, looks at how Oxleas Advanced Dementia Service provides care co-ordination, and specialist palliative care and support to patients with advanced dementia living at home. Read more »
- Somerset dementia strategy
Somerset dementia strategy provides a framework to implement improved, responsive and quality services for people with dementia and their carers across Somerset. The accompanying action plan outlines work underway to achieve the strategy objectives. Read more »
- Specialty Training Registrar (STR4) GP trainee
NHS Cornwall and Isles of Scilly, with SW Peninsula Deanery have funded one Specialty Training Registrar (STR4) GP trainee to work with local general practices to develop understanding about, treatment and care for people living with dementia. Read more »
- Sussex Admiral Nurses
This project aims to commission Admiral Nurses to provide specialist and personalised support to people with dementia and their families and carers in Sussex. Read more »
|
| Engage with deaneries to promote access to training and education for pre- and post-registration medical staff, including GPs. |
| Ensure each General Practice has a named clinical lead, or champion for dementia. |
| Promote and facilitate networking between dementia clinical leads / champions. |
| Work with primary care commissioners to ensure that standards of care and support are in place in primary care for people who have a diagnosis of dementia, and their carers/families – both for those living at home, or in care homes. |
| Work with general practices to ensure that the case management role of the general practitioner is recognised and effective. |
| Facilitate the identification of learning and development needs within general practice, and support local improvement plans. |
| Promote awareness and understanding of the role of health and social care, the voluntary and community sector, and the independent sector in supporting people living with dementia in the community, and in care homes. |
DRIVER: Carers support
| Actions |
Resources |
Examples |
| Ensure carers have timely access to carers’ assessments, flexible respite, carer’s breaks, education, single point of contact 24/7. |
|
|
| Ensure carers are signposted to social care to access Carers’ Assessments (Carers Recognition and Support Act, date) |
| Capture feedback and outcomes from carers of people living with dementia, in order to establish quality of experience and standards of care. Use this information to inform local service improvement and (re) design. |
| Ensure carers receive regular health checks, and engage with health promotion opportunities. |
DRIVER: A skilled, compassionate workforce
| Actions |
Resources |
Examples |
| Consider range of relevant service contracts, and build in to contracts standards for staff competence in working with people living with dementia |
|
|
DRIVER: Timely, accessible information
| Actions |
Resources |
Examples |
| Ensure patients and carers/families have access to a range of information about memory problems, and dementia. Build this requirement into contracts, making use of a range of media and ensuring that that information meets people’s changing needs. |
|
- Dementia awareness resource pack
This pack contains a selection of quality assured awareness raising resources designed to promote living well with dementia. The resources include leaflets, factsheets, contact lists and a DVD. Read more »
- Sheffield dementia information pack
This pack provides a guide to the medical, care, support and advice services in Sheffield and to living well for those worried about their worsening memory problems and those with a diagnosis of dementia. Read more »
|
