Dementia DES "High Quality Care for All, Now and for Future Generations"

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1 Dementia DES "High Quality Care for All, Now and for Future Generations"

2 Dr Sara Humphrey GP Westcliffe Medical Practice GP with a Special Interest in Older People-BTHFT Clinical Specialty Lead Older People & Stroke Bradford District & City CCGs GP Advisor Yorkshire & Humber Dementia SCN 1/7/15

3 Dementia DES 15/16 This is the ORIGINAL screening DES which we have signed up to for the last 2 years

4 Dementia DES 15/16 This enhanced service has been designed by NHS England to reward GP practices for undertaking a proactive approach to the timely assessment of patients who may be at risk of dementia. The DES has been rolled forward to 2015/16 We need to ask the same group of at risk patients about their memory but we have excluded the patients asked in 14-15

5 Aim of the DES a) identify patients at clinical risk of dementia; b) offer an assessment to detect for possible signs of dementia in those at risk; c) offer a referral for diagnosis where dementia is suspected; and, d) support the health and wellbeing of carers for patients diagnosed with dementia. e) Offer all newly diagnosed patients an advanced care plan

6 What is new for 15/16 This year NHS England have also added in COPD patients over 60 yrs and those aged over 60 yrs at high-risk of CVD How have we defined at risk of CVD Those on a Statin for primary prevention who also have a QRISK > 20% already recorded on their notes -Those people who are invited in for an NHS health check

7 DES Sign up as at 2 nd July CCG No. of practices signed up to DES Total no. of practices % sign up AWC Barnsley Bassetlaw Bradford City Bradford Districts Calderdale Doncaster East Riding CCG HRW HaRD Hull Kirklees Leeds North Leeds South & East Leeds West NE Lincs N Lincs Rotherham Scarborough & Ryedale Sheffield Vale of York Wakefield

8 What is the new risk category doing to the numbers Example: Practice A Total Population 11,322 Known Patients with Dementia 103 Prevalence 84.2% No. included on Dementia DES work to do list = 840 No. on list due to high-risk CVD = 181

9 Tools to support the implementation An Organisational Group in import tools Technical Guidance in each search/template Dementia DES searches and reports Dementia DES template Carer Template Advanced Care Plan Template Mental Capacity Act Template

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11 Sign up to YHCS resources as at 1 st July NHS Airedale, Wharfedale and Craven 4 NHS Barnsley 3 NHS Bassetlaw 0 NHS Bradford City ALL* NHS Bradford Districts ALL* NHS Calderdale 4 NHS Doncaster 7 NHS East Riding of Yorkshire 8 NHS Greater Huddersfield 5 NHS Hambleton, Richmondshire and Whitby 4 NHS Harrogate and Rural District 10 NHS Hull 7 NHS Leeds North 3 NHS Leeds South and East 4 NHS Leeds West 1 NHS North East Lincolnshire 4 NHS North Kirklees 8 NHS North Lincolnshire 5 NHS Rotherham 5 NHS Scarborough and Ryedale 0 NHS Sheffield 15 NHS Vale of York 6 NHS Wakefield 6

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13 Dementia DES searches and reports Practices can download searches from the CSU These identify the high-risk patients, add a reminder on the home screen and a link to the template The Work to do can then be monitored under Clinical Reports Switch off SystmOne alert

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16 Dementia DES template

17 Carers template The GP practice will seek to identify any carers of a person with dementia identified in this way (where that carer is registered with the practice) and offer a carer s health check GPs may be asked to do a Carer s assessment for a patient with Dementia on another practice s list

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20 Advance Care Plan Template We also have to undertake an ACP on all new Dementia Patients (diagnosed > April 14) It is suggested you give the ACP document to the patient and family to consider and then invite then in for a guided discussion and to record the summary details on the template

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25 Thank You! (Clinical Guidance) (Technical Guidance) (Implementation & roll out)

26 Any questions?