|Contact||Richard Fradgley, Deputy Director of Mental Health and Joint Commissioning, NHS Tower Hamlets Clinical Commissioning Group|
|Address||2nd Floor Alderney Building, Mile End Hospital, Bancroft Road, London, E1 4DG|
The introduction of an integrated, patient centred dementia service has had a positive effect on diagnosis rates and cost effectiveness in the London Borough of Tower Hamlets.
Within a year referrals to the memory service doubled, with a particular proportionate increase in the Black and Minority Ethnic community, and in 2012 the diagnosis rate increased by 9.6% to 50%. A reduction of 11,000 bed days previously used for assessments has enabled a reduction of 23 inpatient beds.
Between 2009/10 and 2010/11, national improvement statistics showed that Tower Hamlets Primary Care Trust (now Tower Hamlets CCG) had been unsuccessful in improving their dementia diagnosis rates. The Trust was second to last in PCT dementia performance improvement in London, with low recording on the primary care register. Dementia services were part of a general Community Mental Health Service for Older Adults. Memory services were not commissioned.
Service users and carers said that their experience was fragmented. They perceived that getting a referral for specialised assessment ‘was a battle.’ Once the assessment was complete they would often have to be referred separately to the Council for a social care assessment and on again for an assessment by a geriatrician.
Care staff reported having little understanding of dementia as a condition let alone how to work in a person-centred way with someone who had dementia.
A further challenge for the dementia partnership was engaging local communities. Typically the ethnically diverse resident population tended not to seek help, making late presentation a big problem.
Opportunities and actions
Tower Hamlets used the opportunities the National Dementia Strategy published in 2009 provided, as a way of developing what good services should look like.
The Trust set up a leadership coalition with carer, public health, commissioner and provider representatives, which became the Tower Hamlets Partnership. The partnership included users and carers, psychiatry, social care, GP’s, Alzheimer Society, Age Concern and commissioners.
From the outset the principles that were agreed were based on a strong conviction that through joint commissioning the partnership could harness opportunities for integrated health and social care pathways. The views of all the partners were captured in Tower Hamlet’s Joint Strategic Needs Assessment document.
The strategy developed a structured three year awareness raising plan based on the best available evidence. It specifically looked to address:
- The stigma and consequences of poor access to services that people with dementia may experience
- The benefits of timely diagnosis and care
- Awareness of dementia in the Bangladeshi and Somali communities.
This process enabled Tower Hamlets to design a clear pathway and to secure the funding needed for commissioning new services.
The new services
Tower Hamlets commissioned a whole range of new services, with a coherent community pathway that was entirely integrated across health and social care. This included:
- Diagnostic memory clinic
- Community Dementia Team
- Dementia Adviser Service
- Homecare services re-tendered: specific requirements relating
to users with dementia
- Dementia Liaison Service at the Royal London Hospital
- Extra care sheltered scheme for people with dementia
- Dementia café.
As part of the community awareness-raising activities, a member from the Alzheimer Society trained 120 local Imams to understand dementia and its issues. This resulted in the Imams delivering special sessions devoted to teaching the local community about dementia in their mosques.
When a service user attends the diagnostic memory clinic, the assessment is holistic. They see a psychiatrist / psychologist as routine and may see a geriatrician, social worker or nurse if appropriate to their needs.
They will be offered post-diagnostic counselling and pastoral support by the Alzheimer’s Society Dementia Adviser Service, which is co-located with the Memory Clinic.
Any person with a diagnosis of dementia in the borough will now be offered the telephone number of a health and social worker who works in the dementia pathway. This could be a Dementia Adviser, if the person has mild problems associated with their dementia, or a doctor or nurse from the Community Dementia Team, if they have more complex problems.
The Community Dementia Team provides on-going support for anyone with moderate to severe needs and also provides outreach into care homes and into primary care. The team also provides various therapeutic groups.
Tower Hamlets also commissioned a range of social care services. In addition to the existing specialist day centre, there are also very well attended dementia cafés provided by the Alzheimer’s Society. One café provides specific support for the Bengali community and one is for all comers.
Between 2010/11 and 2011/12 the impact of the new pathway has been profound.
Referrals to the memory clinic have almost doubled in the space of a year. Inpatient bed days that were occupied for dementia assessment have reduced by over 11,000 throughout the Mental Health Trust.
With the new services proactively supporting people closer to home, Tower Hamlets worked closely with their neighbouring areas of Newham and City & Hackney to reconfigure inpatient dementia beds as all three areas are served by the same partnership trust. These have been reduced from 44 to 21, with a resulting release £1million of funds. As of October 2013, there are only 8 patients on the ward.
Prior to commissioning the new services, only 10% of referrals were from the Bangladeshi community even though the local population is 33% Bangladeshi. Through the support of a Bangladeshi outreach worker, Bangladeshi referrals of people from the Bangladeshi community are now thought to represent approximately 20% of the total.
People assessed as having dementia in acute care has increased. The people with a confirmed diagnosis of dementia recorded on the primary care dementia register increased from 40.3% in 2011 to 50.0% in 2012, a 9.6% increase, making Tower Hamlets the most improved organisation in England over this period.
The partnership is now building dementia and mental health expertise more generally into its new integrated care system.
“Very thorough discussion regarding the assessment process and the diagnosis result was relayed in the nicest fashion.”
Service user, Memory Service National Accreditation Process
“Good continuity and letters. Excellent nurses. I have been called by their doctors about patients and also to tell me changes in care. They seem very good. They do home visits – doctors seem motivated and caring.”
GP, Memory Service National Accreditation Process
“It was good to get out of the house. Thank you very much for putting a smile on our faces.”
“It brought Jane to life: it was a lifesaver.”