Understanding Dementia Care in NW London Integrated Care System
The Bi-Borough PBP Dementia OPPN event in NW London aims to provide insights into the NHS Integrated Care System, dementia services, local strategies, and available support for individuals with dementia. Key points include national and local data, memory assessment services, and post-diagnostic support. Providers share their perspectives on working with dementia patients and their carers. The session includes a dementia poll to gauge knowledge and awareness levels among attendees.
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Bi-Borough PBP Dementia OPPN Date: Tuesday 4thOctober 2022 Lisa Cavanagh NW London ICB Alison Wragg CNWL Luke O Connor CNWL Nick Murray - CNWL Janet McCormick Campbell - CLCH
Purpose We are aiming to: Give an overview of NHS NW London Integrated Care System (ICS) , the Bi-Borough Place Based Partnership (PBP) and where dementia fits in. Given an outline of: o National and Local Strategic Direction o Our local population o Integrated Memory Assessment Services o Post diagnostic support services o Local work and priorities Hear from providers about their understanding, knowledge and experience of the local offer for people living with dementia and their carers. 2
OPPN dementia poll 1. Do you work with and/or deliver services to older adults and/or their carers? 2. Do you have personal experience or know someone who is living with dementia? 3. Do you work with and or/deliver services to people with memory loss, e.g. Cognitive Impairment (CI), a diagnosis of dementia or their carer 4. On a scale of 0-5 , 0 being no knowledge , 5 being very knowledgeable, how would you rate your knowledge/understanding of memory loss, CI or dementia as a condition. 5. On a scale of 0-5 , 0 being no knowledge , 5 being very knowledgeable, how would you rate your knowledge of what local services are available to support someone living with dementia and/or their carer? 6. Do you know where to signpost/refer someone for a dementia diagnosis? 7. Do you know who to contact for information and advice on dementia? 3
NW London Health and Care System The North West London Integrated Care System (ICS) is a collaboration of NHS, local authority, voluntary and community sector organisations A video to help explain NW London ICS https://youtu.be/M8OsTHOVGWE Bi-Borough Place Based Partnership has x5 local priorities, one of which is mental health which has x4 transformation areas. Older Adults is one of the transformation work streams and includes dementia. A Bi - Borough dementia task & finish group with representatives from across the system is in place to help support and deliver local priorities. PBP Mental Health Partnership Forums are in place in Kensington and Chelsea and Westminster and open to any VCS and statutory/non- statutory organisations to join. 4
National and Local Data and strategy There are around 850,000 people living with dementia in the UK. Over 42,000 of these are under 65 years old (early onset dementia). If current trends continue the number of people with dementia in the UK is forecast to increase to over a million by 2025 and over 1.6 million by 2051 Westminster o Older adult population (65+yrs) is 33,900 (mid-year ONS 2020) o Estimated prevalence 65+ years (April, 2022) is 1,510 o Number on dementia register, 65+ years (April, 2022) is 953 Kensington and Chelsea o Older adult population (65+yrs) is 25,596 (mid-year ONS 2020) o Estimated prevalence 65+ years (April, 2022) is 1891 o Number on dementia register, 65+ years (April, 2022) is 1233 Strategy o NHS Mental Health Long Term Plan o Living Well with Dementia Strategy o NHS NW London Memory Assessment Service Specification 5
KCW Memory Service 1. Operational since September 2009 2. Community-based at 42 Westbourne Park Road 3. MDT:Psychiatrists, Dementia Nurses and Admiral Nurses, Occupational Therapist and Psychologists 4. Offer- Timely diagnosis, post diagnostic care planning/ therapeutic groups, Carer support/ advice, Training and education. 5. Post pandemic challenges- team redeployed twice during pandemic, staff burn out, accessing vulnerable service user group. 6. Goals reduction of waiting time, high quality assessment, integrated delivery of post diagnostic inventions, improved carer support. 6
My Care My Way Memory Assessment Service The Integrated memory assessment service was phased in to incorporate MCMW in 2018/2019 and assess people 65 years and above residing in K&C Works in partnership with KCW Memory Service 8 Assessors who also provide case management responsibility for other patients with Long term conditions and cover 5 PCN. Challenges : Staff redeployed during the pandemic, not a standalone service as has other competing demands, staff turnover, not enough assessors to meet the 6wk wait for assessment. Aspirations: Meet 6 week target. Have more trained assessors who solely provide memory assessments. 7
CNWL K&C Older Adult Community Mental Health Service CNWL K&C Older Adult Community Mental Health Service The team is based on the St. Charles site and covers the whole of the Borough of K&C. The team is proactively recruiting staff to ensure that it is well positioned to address post Covid demand and ensure that patients can be seen in their own homes. The team is a specialist multi-disciplinary service for older adults consisting of psychiatrists, community psychiatric nurses, occupational therapists, psychologists and social workers. The team works with older adults with complex functional and/ or organic mental disorders (such as depression, schizophrenia, dementia). The team ensures that there is a timely and holistic assessment of patients with a cognitive impairment, where the needs are complex and may involved risk, and provides a diagnostic and care planning service. The team provides recovery focused and evidence based treatment and care which can include psychological interventions, occupational therapy and arts therapies. 8
Dementia Pathway Mapping DIAGNOSIS WELL TREATING WELL SUPPORTING WELL LIVING WELL DYING WELL Post diagnostic support services / interventions Memory Assessment Referrals Triage Diagnosis VCSE Partners K&C Westminster Dementia Advisor Westminster Inc.. Dementia Cafes North and South (London Care Ltd) Dementia Cafes , Maintenance CST, Befriending (Age UK Westminster) Bi-Borough Resonate Arts Programme including Creative Befrienders (Resonate Arts), Music for Life care home projects (Wigmore Hall); Music for Thought, Singing with Friends and Music for the Moment (Wigmore Hall, Resonate Arts & Royal Academy of Music) At Home Respite, Dementia Advisor and Volunteer Coordinator, My Memories Caf , Carers Support, Maintenance Cognitive Stimulation Therapy CST (Age UK K&C) Connect (Resonate Arts) , 1:1 support (Age UK K&C) part of MCMW pathway Memory Assessment Service (MAS) My Care My Way (MCMW) - WL only >65 s Majority of PC based referrals Step up most complex to KCW MAS Kensington and Chelsea and Westminster Memory Assessment Service (KCW MAS) CNWL All age inc young onset Complex presentations Twice weekly MDTs - MCMW & MAS cohort Local Authority Community Services RBKC Age UK Dementia Outreach & Befriending (joint funded with health) Day Centres: WCC Westbourne Road Dementia Day Centre RBKC Chamberlain Dementia Day Centre RBKC Pepper Pot OP Day Centre, RBKC Kensington OP Day Centre @ The Reed, WCC Pullen OP Day Centre, will all support residents with dementia even though not labelled as dedicated dementia resources. Accommodation WCC Penfold ECH & Leonora ECH both have dedicated dementia units for more progressed cognitive impairment. All the ECH schemes however will support a level of dementia / cognitive impairment. WCC Beachcroft, WCC Forrester Court, RBKC Ellesmere will all have dedicated dementia units. WCC & RBKC Behaviours That Challenge Service Carers Services WCC & RBKC Carers Network - There services include dedicated dementia forums. RBKC Open Age - Time for Me will include carers of those with dementia Older Adults Community Mental Health Team (OACMHT) All referrals have routine cognitive screen Any age service, Includes those with Complex behaviours and young onset. Others Acute trusts: Neurology, Geriatricians Care Homes: OA geriatricians Memory clinic Chelsea & Westminster Hospital Health Primary Care/GP Cognitive Stimulation Therapy (CST) groups (joint with Resonate Arts/V&A) Admiral Nursing (Bi-Borough) Chinese Speaking admiral dementia nurse - Westminster (pilot) Older Adults CMHT (Bi-Borough) Music/Art therapist (via Older Adults inpatient wards) Mainstream Community Offer including Domiciliary Care Services KCW Dementia Action Alliance 9
Our Local work and priorities Dementia Standard Work areas - TBC Local waiting time till diagnosis meets standards (average days to diagnosis and diagnosed within 6 weeks from KPIs) Access to local MRI provision. Review of referral form via GPs Readjusting priorities and working with VCS to deliver psychosocial interventions i.e. CST. 1. Access to service by ethnicity compares to local population demographics Work with Public Health to access local population ethnicity data. Look at MAS access data by ethnicity of those diagnosed. PCNs work re: updating patent records with ethnicity and first language as per national requirement. 2. GP training provided A training needs analysis to determine requirements Identify GP practices to target via review of incomplete/rejected referrals . 3. Link to local VCSE and local authority services providing pre and post diagnostic support via dementia link or support workers Review of ICB commissioned VCS dementia contracts Commissioning and Procurement proposal 4. 10
Breakout groups Group discussion - 15 mins 1. How are the VCSE engaged at a Primary Care Network (PCN)/grass roots level i.e. MDT s etc. 2. How do the VCSE have their voices and experiences heard across the system and at a place based level? 3. What are your thoughts, comments or questions on what you have heard? 4. Does it resonate with your experience, are these the right priorities, any gaps other considerations? Group feedback 10 mins 11
Thank you for listening If interested in joining the K&C and/or Westminster Mental Health Place Based Partnership Forums please contact m.waters1@nhs.net 12
