Dementia Friendly

Practices in Thames

Valley – Learning &

OpportunitiesReview & Resources

Pilot developed in partnership

with:

Principles - SPACE

Image: http://wessexahsn.org.uk/img/projects/Dementia%20Friendly%20Surgeries%20brochure.pdf

• When considering

supporting excellent

dementia care in whichever

environment, these 5

principles – known as SPACE

need to be in place

• A commitment to these

principles are crucial for a

team, organisation,

or site to consider

and plan patient-centred

care to deliver

for patients and their

carers

The Aim: To support the creation of

exemplar GP practices in Thames Valley

• In November 2014, TV SCN and Health

Education England launched a joint scheme

inviting local GP Practices to bid for funding

which would support them to become

‘dementia friendly’.

• Using the King’s Fund Health Centre

Assessment tool in the evaluation of the bids,

TV SCN awarded three practices as part of

the scheme;

• These practices aimed to improve the

physical environment of the

practice, staff awareness and

training and their own

management processes to ensure

patient and carers receive the care and

attention they require when visiting the

practice

Image reproduced by Flickr user - http://bit.ly/29qtF3A

under Creative Commons - http://bit.ly/29rePKm http://bit.ly/1rMF155

• Bedford Street Surgery, Milton

Keynes

• John Hampden Surgery,

Prestwood

• Trinity Health Centre, Long

Crendon, Aylesbury

with a further award to;

• Sheet Street Surgery, Windsor

Staff Awareness, Knowledge &

Understanding

Key Focus: Raise awareness and build confidence in staff when dealing with

dementia

• All staff and patient participation groups received Tier 1

and more specific Tier 2 Dementia Training (provided by

Health Education England Thames Valley Dementia

Academic Action Group) to learn about what is it like to

live with Dementia and recognise and assist patients and

carers in accessing support and services

• New roles were created in practices to create a supportive

culture operationally (“Dementia Guardians” – looking out

for patients when visiting the site) and strategically

(“Dementia Champions” – embedding the principles)

• Practices engaged with other clinical staff from across the local NHS system including

Older People Mental Health Consultants and Memory clinics to review pathways and

share knowledge.

Partnership Working

Key Focus: Involvement of varied stakeholders not only for patients, but carers and wider communities’ benefit

Patients and carers have;

• Been engaged in their journey through the “This is

Me” resource

• Been supported to create collaborative advanced

person-centred care plans

• Been encouraged to discuss

End of Life care plans including

Lasting Power of Attorney

The community have;

• Been aligned to ensure post-diagnostic services (e.g.

“Prevention Matters” in Bucks) are signposted

• Worked with local support groups, churches, local

authorities and charities to create “communities of

interest”

• Considered practices joining a “Safe Place” scheme to

strengthen community support

• Worked with local groups to support artistic

activities such as “Singing for the brain”

Clinicians in the practices have;

• Created Multidisciplinary Teams – including social care, community practice workers, pharmacy,

community psychiatric and palliative care nurses to discuss and plan patient care

• Developed Dementia Support Nurse capacity through training

• Strengthened Named GPs and Support worker involvement throughout a patient’s condition

• Engaged pharmacy to undertake medicine management audits (particularly anti-psychotics), safe

medication usage, dosette boxes, compliance etc

Patient

Carer

Family

Process Improvements

Key Focus: Simple process changes in GP practice, to yield a more systematic approach

to supporting those with Dementia

Practice Leadership – Create a culture of “No stigma” around Dementia

Proactive

Patient

information

• Leaflets

• Waiting room

Screens

Assessment

• Systematic

use of “This

is Me”

• Home visits

if

appropriate

• Referral to

specialist

support

Coding of patients to unlock the support they

need

Use of agreed

codes;

• Dementia in

Alzheimer’s disease

Eu00

• atypical or mixed

type (mixed

Dementia) Eu002

• Vascular Dementia

Eu01 or

• Unspecified

Dementia EU02z

System cleanse

to ensure all

codes such as;

• h/o dementia,

cognitive decline

• mild memory

disturbance,

• memory

impairment

are checked and

converted to the most

appropriate code once

a formal diagnosis is

made

Create

Alerts

Once coding is

complete, set

Dementia

Alerts on

patient records

Changes to

Appointment

System

• Double

appointments to

allow patient and

carer enough time

• Proactive follow up

of Did Not Attend

(DNA)

appointments

• Memory prompts

for appointment

reminders – either

via carer,

telephone or text

Carers Support

Key Focus: To acknowledge and holistically support Carers’ efforts , their health and

the role they play in Dementia care

CarerCarerCarerCarer

Pilot Practices reviewed their care and support to ensure;

Carers are identified and

written to, encouraging

engagement and offer of

support

Carers included in all patient

correspondence (consideration needs to

include hospital and other interactions - with

consent)

Carers are offered a

physical “health check” (blood pressure, weight,

depression screening, smoking,

diet and alcohol support)

Carers are offered an

emotional “health check” – to

offer a level of support through

regular review, referrals to CBT and

specific CBT for carers and carers

break funding (if applicable)

Practical advice for Carers is

incorporated in support sessions e.g. Carers’

Register, grants, sitting services, access to

non-pharmalogical aides)

Information and signposting is

available (e.g. Alzheimer's Society

resources)

Active links with local Carers support

charities, support groups and local

authority advice and guidance – information

can be accessed via the Carers Trust

Dementia-Friendly Environments –

Trinity Health, John Hampden & Bedford Street

Key Focus – To enhance the physical

environment

Practices implemented;

� aesthetic changes to create a less

confusing environment (plain coloured

walls/contrasting frames and

skirting

� improved visual signage and

installed dementia friendly

clocks to simplify and aid

orientation

� music systems in waiting rooms

� a “sensory garden” concept and design, after consultation

with patients and carers

Power of Attorney

Oct-13 2

Apr-14 4

Oct-14 21

Apr-15 25

Oct-14 44

Apr-15 25

Oct-15 44

Apr-16 46

DNACPR in place

Apr-14 5

Oct-14 36

May-15 31

Sep-15 33

Apr-16 33

Patients Admitted

Sep 13-Mar 14 6

Apr 14 - Oct 14 15

Nov 14 - Apr 15 10

May 15 - Oct 15 12

Nov 15 - Apr 16 16

“This is me”

Oct-14 15

Dec-14 25

May-15 36

Jun-15 39

Jul-15 41

Jan-16 51

Dementia Diagnosis

Apr-12 50

Apr-13 60

Apr-14 86

Oct-14 105

Apr-16 112

KPI Target (Q4) Q1 Q2 Q3 Q4

Dementia Friends 100% 100% 100% 100% 100%

Dementia Awareness;

staff to be Tier 1

trained

90% 71% 71% 71% 92%

Named GP for each

patient with

Dementia

100% 100% 100% 100% 100%

Patients to complete

a This is Me

document

85% 12% 32% 56% 64%

Identified Prevalence 67% 48% 60% 68% 68%

Annual Review

(including

medication)

95% 28% 64% 83% 96%

Next of Kin recoded

on Records

100% 40% 96% 96% 96%

Dementia Care Plan

shared on Summary

Care Record

100% 20% 48% 100% 100%

Results from John Hampden Surgery (Thames Valley) Dementia Friendly

KPI’s - March 15- March 16

N.B. number of patients - with a list size of approx 11,000

Results observed from Best Practice Site (Not Thames

Valley - Oakley & Overton Partnership, Hampshire)

Sept 2013 – April 2016

Pilot Outcomes & Impact

Resources

Kings Fund Assessment

tool – Health settings

Information on Merton

Dementia Hub

Dementia diagnosis

and management

A brief pragmatic

resource for general

practitioners

“This is me” –

personalised

preference tool to

help

professionals

understand

individual needs

Infographic –

Aims & Objectives

of John Hampden

Surgery project

Implementing

Dementia Friendly GP

Surgeries – Wessex

AHSN

Health Education

England – Training

resources provided by

the TV Dementia

Academic Action

Group (DAAG)

Alzheimer’s Society

Resources

Dying Matters – End of

Life information

Support for community

engagement and

partnerships in Dementia

Help and advice

for Carers

Customer-facing

Staff Handbook on

how to help people

with Dementia

“I am passionate about identifying our patients with

dementia. Being diagnosed in a timely way will enable

patients to access the right treatments and find the best

source of support, as well as being able to make

decisions about the future.

In doing so, patients can “live well” with dementia

and maintain a good quality of life”

Dr Sian Roberts – John Hampden Surgery

This work has been delivered in partnership between Thames Valley

Strategic Clinical Network and Health Education England – Thames

Valley

Our thanks go to all staff and patients at the participating practices;

• Bedford Street Surgery, Milton Keynes

• John Hampden Surgery, Prestwood

• Trinity Health Centre, Long Crendon, Aylesbury

• Sheet Street Surgery, Windsor

And also to Dr Nicola Decker – North Hampshire

CCG Clinical Lead, Dementia for her Dementia

Friendly Practice work and for sharing the excellent

results achieved at Oakley & Overton Partnership