Dr Pippa Stables Lead GP for Dementia. Bristol Clinical Commissioning Group

Transcription

1 Dr Pippa Stables Lead GP for Dementia Bristol Clinical Commissioning Group

2 Bristol Primary Care Dementia Service Integration in Action

3 Background Bristol CCG has transformed the dementia service from being managed entirely within secondary care to one delivered predominantly in primary care with support from specialists. Until 2012, a largely traditional model of dementia care existed with referrals of all people with symptoms of dementia to an acute mental health memory clinic based at Southmead and Callington Road Hospitals.

4 What we did A GP clinical lead for dementia, Peter Brindle, was appointed and a Dementia Health Integration Team (HIT)established. Supported and led by Emma Moody in the CCG. Workshop held to explore what the perfect service would look like. Two main work steams emerged: Dementia diagnosis in primary care Dementia wellbeing service

5 Dementia diagnosis in primary care Education and training: A GP lead for education was appointed linking GPs and specialist teams to build trust Designated GP lead for dementia in each practice Primary care pilot: 11 practices evaluated by UWE Positive results led to the roll out across the city Enhanced service agreement: recognising that GPs delivering a service over and above their contract Almost all GP practices are signed up.

6 Engaging GPs- Educational messages- Workload Core Primary Care work returning home It is low risk, doesn t need high tech approach We are doing this work anyway, in many ways Increasing confidence and ownership reduces frustration Excellent support from memory nurses & Carers organisation Realistic pricing of GP and practice nurse time

7 Engaging GPs- Educational messages Early diagnosis benefits patients & carers Helping patients to do what they want to do for as long as possible Relationship-centred care Integration of physical and mental health care Care closer to home Lifelong care, never discharged, EoL care Support & resources for carers (PoA, breaks)

8 Engaging GPs- Educational methods Education time funded via LES Pilot practices: practice based, small groups Now offer choice of dates & days 3 x a year Whole or half days, GPs and Practice nurses Interactive, rotating workshops Lots of opportunities to meet wider team- Carers Support Centre, Housing 21 EoL care nurse, Community Nurses, Carers & Lived experience

9 Engaging GPs- Educational methods Helps with CQC and Hot Topics GP led, learning needs assessed / aware Safeguarding Adults Mental Capacity Act Deprivation of Liberty Safeguards Care Act Admission Avoidance Care planning

10 Tackling Inequality in Dementia and Raising the Bristol Standard 9.00 Coffee for 9.15 start choose 3 workshops, 1 hour each: Behavioural and Psychiatric problems in dementia, focus on prescribing and this year s Medicine s Management Audit of anti-psychotic prescribing with Dr Colm Owens Dementia in BME groups, diagnosis and Care: Angela Etienne, Community Development Worker and Dr Kim Hallett Assessing Mental Capacity, DoLs and safeguarding Dementia patients: Research in Dementia- how can you or your patients take part, and what is the latest Lunch Care Planning in Dementia 3.00 to 4.30 working in locality groups with your service lead practitioners and Navigators

11 Modernising Mental Health Enabled the complete redesign and re-commission all the community dementia services. Major consultation exercise held Main finding: Services needed to be more focussed on relationship - centred care which emphasised the needs of family and carers to ensure ongoing wellbeing Dementia separated from mental health services Service specification for new service co-produced involving those with lived experience

12 Dementia Wellbeing Service Devon Partnership Trust and the Alzheimer's Society won the tender Service was fully implemented on April 1st 2015 The service employs 24 dementia practitioners and 24 dementia navigators based in three hubs The service provides named support to every GP practice and care home

13 Dementia Wellbeing Service The service provides: Support for primary care to diagnose and manage dementia including medicines management A single point of access for referrals and advice to professionals, people with dementia their families/carers Dementia wellbeing plans for everyone A service that supports people s dementia and their other mental health problems

14 Dementia Wellbeing Service A focus on prevention and care planning Ongoing support from dementia navigators A one stop memory clinic for complex dementias Support to people in care homes with dementia and other mental health problems Crisis support.

15 Impact on Carers

16 Impact on GPs (from recent GP survey) Overwhelmingly the biggest challenge is respite facilities for carers (GP) [now have flexible short term beds pilot at Robinson House] 73% of GPs rated the service as excellent or good at helping to effectively manage people with dementia and their family and carers.

17 September 2012 October 2012 November 2012 December 2012 January 2013 February 2013 March 2013 April 2013 May 2013 June 2013 July 2013 August 2013 September 2013 October 2013 November 2013 December 2013 January 2014 February 2014 March 2014 April 2014 May 2014 June 2014 July 2014 August 2014 September 2014 October 2014 November 2014 December 2014 January 2015 February 2015 No of Referrals Impact on Referrals Bristol Memory Service Referrals Acute Memory Service Primary Care Diagnosis

18 Impact on Data Collection We now have a full data set on age and BME background of people with dementia to inform future commissioning

19 Impact on People with Dementia Mrs P had stopped going out since the death of her friend. We discussed what she used to like and I offered some activities that I would take her to try. Mrs P said she would not like to try these things as she is happy at home and scared of buses, having fallen off one many years ago. On my next visit I broached the subject again, but this time asked Mrs P if she would accompany me to an activity which I had not been to before and would value her feedback. Mrs P said this was in the area she grew up in and if it helps then she would try it. We had a good few hours out, and Mrs P has agreed to try the Withywood Activity Group with me next month.

20 Impact on People with Dementia I was recently visiting with Mr C, and his daughter D. Whilst discussing information for carers, D and I also talked about the different activities in the area for Mr C. I have given lots of info and have discussed how I can further support her. D s words to me were, I thought I had nobody to turn to before, but now I know you and have your support - I feel I am not in it alone anymore and I have got someone to talk to.

21 Wellbeing Service at 1 year Old We have some challenges Over stretched GPs who don t engage Over stretched Dementia Practitioners at times trying to work with the thoroughness of a consultant with the case load of a GP Case load growth from 20 to 200

22 Celebrating success

23