Transcript Developing a service: a personal story

Early Intervention in DementiaA new service in Worcestershire
Bernie Coope
Lead Consultant for Old Age Psychiatry
Worcestershire
What this talk covers
 The journey for developing a new service
 A brief description of our service model
 Things that have worked and things that haven’t
 Encouragement to get out there and do something
Why do you come to work? (Or “Isn’t this someone else’s job?)
 Do you come to work to improve the lives of people touched by mental
illness?
 If so, how broad is your job?
- Delivering a service
- Teaching others to deliver a service
- Auditing a service
- Changing a service
- Creating a service
And isn’t it more rewarding to do all of the above?
Long, long ago, before the National Dementia Strategy
 Mental Health Strategy for the county was 16-65 (i.e. Mental Health NSF)
 No new development for older people for some time
 Modernisation largely saw money leave older people’s service e.g. closing
continuing care
 No commissioning ownership-no one to talk to.
 Dementia seen as unimportant
 Only interest in dementia was focused on drug treatment (“You’re
prescribing too much”)
 Trust performance indicators focused on younger people
But
 Dementia growing -3%PA in Worcestershire
 Rapidly changing presentation to the service reflecting changing
expectations of population “I’m worried I might have Alzheimer's’”
 National Audit Office Report showed need and cost of not doing
something
 NICE/SCIE Guidelines
The start-can hate be good?
What was there to hate-local and national
 A reactive service
 Referral at time of crisis
 No user choice
 Burnt out carers
 Limited therapeutic options
 Most people with dementia not coming near our service
Had a good moan at NIMHE
 FRUSTRATION- BLOODY GOOD NEWS STORIES
 Wrote and got a reply
 Had a moan to David Shires (Bloody discrimination, choice, too late,
exhausted families etc)
 He said “This is why we set up an Early Intervention Service for
Psychosis”
 A Eureka moment
Developing the model-Form a group!
 Remit- Is there a better way of addressing the needs of people presenting
now
 Involved professionals
 Alzheimer's Society
 For Dementia
 Carer consultation and input to model
 Rapid development of principles
 Used “Early Intervention” to distinguish from “Memory Clinic” and because
of strong image in Trust
Principles
 To improve the lives of those affected by dementia
 Respond to demand from population, early assessment, more
assessment
 Swift, skilled assessment
 Choice all the way along (to be assessed, to hear outcome, choice for
future)
 Skilled communication of outcome
 Support following diagnosis for a period of time
 Continual evolution, especially from feedback
What is Early? Contrasting views
 2/3 never get a diagnosis, so before death is early.
 Most of what can be described as intervention could be relevant to
anyone, it’s never too early, let’s push the boundary
 Personal view- Dementia includes significant impact on lives, conspicuous impairment
- Confidence in diagnosis
- Early enough to retain information and make choices
- Risk of harm
- Risk of wasting resources
What is an Intervention
 “After diagnosis people want to be shown the path, not shown the door”
Terry Pratchett
 Information-Knowledge is power
 Emotional Journey
 Discussion and decision
 Plans
Then The National Dementia Strategy Came Along
 Early Intervention key recommendation
 Financial model and proposed service structure
 We all went to visit Croydon
Fishing or Carving Mount Rushmore?
Be prepared for false summits, lots of them
 Three years I had an excited phone call from CEO
 Email 2007 detailing £1M recurring investment to the service
 Early Intervention “a priority”
 In the age of pointless detail it is surprisingly hard to be clear about money
and time.
A period of hard sell
 Make friends and allies
 “In God we trust, everyone else must bring evidence”
 Sometimes you need detail, sometimes simple messages repeated
 Charming gate-crashing
 Persistence
So what are we doing?
 Newly funded team covering the county (Rejected proposal was
enhanced function of CMHTs)
 Multidisciplinary (Medic, nurses, psychologist, OT)
 Consultations in clinics, surgeries, home
 Make the diagnosis well, share it well and deal with the consequences
 Still working on the detail-support from Worcester University
 Team in post by June (first wave)
Pre-referral
• Awareness of
dementia
• Preventative
measures
• Awareness of
service,
professional and
public
Referral
• Accessible
• Low stigma
• Referral from
primary care,
single point of
referral, also
diversion from
CMHT allocation
meetings
• Physical health
review and bloods
done in primary
care
• Some secondary
care referrals
First Contact
• Team member
• At home
• With Family or
friends
• Choice not to
continue with
assessment
• Explanation of
assessment
process and
possible outcomes
• Supported with
written information
• carried out by
future care
coordinator
Main
Diagnostic
Assessment
Investigation
• In Clinic or Surgery • Brain imaging
• Extended hours is • Neuropsychology
a carer wish
assessment
• Initial joint history
with family, then
split for cognitive
assessment and
carer interview
• Assessment
diagnosis in
accordance with
NICE
• Assessment of
need and risk
Diagnosis
sharing
• In accordance with
previously
expressed wish
• Sensitive and clear
• Usually with family
present
Supportive
work
• Expected to last at
least 3 months
(How long and how
intense?)
• 1:1 and group work
• delivered in
collaboration with
Alzheimer's society
and Admiral
Nurses
• Introduction to
Dementia Advisors
• Legal and financial
advice
• Future planning
(How and what)
• Healthy living
• Coping with
forgetfulness
• Specific carer
advice
Exit early
intervention
service
• Return to primary
care for majority
• GP register and
review as QOF
• Personal letter to
patient from care
coordinator
• Clear letter to GP
covering diagnosis
and advanced
wishes
• Advice on return to
service
Contentious issues
 Who do we not offer a service to?
 What do we offer people with no diagnosis or MCI?
 What do we offer those of working age?
 How long do we see people for?
 What sort of interventions can we offer (e.g. ?cognitive stimulation)
 Why not self referral?
 How do we go about helping people plan for the future, including end of
life care?
 What is the right skill mix?
 What is the right setting?