This document is intended to be a guide to current and potential service providers, signaling the overall direction of travel in relation to dementia services in NEL.
Dementia describes a set of symptoms that may include memory loss and difficulties with thinking, problem-solving or language. Dementia is caused when the brain is damaged by diseases, such as Alzheimer’s or a series of strokes. Dementia is progressive which means the symptoms will gradually get worse and the care needed by someone with dementia will fluctuate and change over time.
Work has been on going to decommission expensive and fixed bed based assets, transferring the resource to more flexible, deployable mode of care delivery centred around people's own homes. As this work continues it requires the development of co-ordination and co-operation between different providers. It will involve an increased role for the community and voluntary sectors in providing support and will require current providers to work closely with the commissioner to ensure this shift in resource and recalibration of current capacity and skillsets.
This table shows the shifts in resources from 2011-2014
The Government published 'Living Well with Dementia: A National Strategy for England in 2009' in response to the need for a national strategic framework for making quality improvements to services for people with dementia, and to address health inequalities. This is interpreted in a local Strategy “Living Well with Dementia in North East Lincolnshire“ and sets out how to meet the needs of people with dementia and their carers, ensuring that their ideas are incorporated where possible.
Following on from the progress of the National Dementia Strategy 2009 the Prime Minister launched The Dementia Challenge in 2012, with the aim of delivering better health and care, creating dementia friendly communities and supporting research. Through the Prime Minister's Dementia Challenge, in 2013 NHS England was able to quantify the first ever national ambition to improve the dementia diagnosis rates. The aim is that by 2015 "two-thirds of people with dementia should have a diagnosis, with appropriate post diagnosis support".
The demand for care and support services from people with dementia and their families is continuing to rise but public spending, especially traditional adult social care spending, will not keep pace with demand. The key messages are:
- As people age, the incidence of dementia will increase and services therefore need to be appropriate to meet these changing needs. Generally people with dementia are entering services much later in life and consequently with more complex needs.
- Increasingly people will seek out solutions which help them to live independently in line with their chosen lifestyle. This necessitates a different approach to traditional modes of service delivery and the CCG will, in partnership with key local providers, re-configure spending to meet national directives while investing in a model of sustainable community and home based provision.
The CCG is in a unique position as an integrated commissioner of health and social care services and as a result, we will deploy both health and social care resources to ensure we are able to provide sufficient capacity in relation to care services.
Life expectancy is increasing so entry into formal long term care is likely to be later in life, with more complex support needs. As a result and in recognition of this, the CCG has commissioned a number of specialist enhanced long term care beds and will review the need for any increase in this.
People who have dementia and community care needs are being encouraged to use personal budgets to buy their own services, with help from support staff. As more people choose this arrangement, providers of services will increasingly be selling directly to individuals rather than to the CCG and this is a major change in the way providers and commissioners do business.
It is important that the CCG works closely with current and future providers to help the current market remain stable and to encourage the development of new, innovative ways of delivering support, stimulating new businesses and organisations.
Key to our approach is working in partnership with people with dementia who need social care services so that we understand their needs and wishes and can enable them to find the support services that they want.
Support a shift towards personalised services that are designed around individual need;
Commission services to:
- place an emphasis on prevention and early intervention, to help people remain independent and to reduce the demand on acute services; and
- promote health and well-being in their widest sense, helping people to have greater control of the services they need, and supporting them to have more responsibility for the management of their own conditions/ situation.
Spending & Demographics
Historically North East Lincolnshire’s expenditure on older people’s mental health services has been above that for other similar areas (ONS cluster – Manufacturing Towns) . Following publication of the National Dementia Strategy (NDS), significant investment has been made in new servies by the CCG in line with the NDS. the CCG is also freeing up resources through redesign and reinvestment in dementia services. Dementia is now high on the agenda of all local organisations and recognised as one of the biggest issues facing them as the number of older people increases in the coming years.
The incidence and prevalence estimates together with North East Lincolnshire’s demographic projections suggest a 29% rise in the prevalence of dementia between 2011 and 2021. The drive toward diagnosing a larger percentage of these people means that the actual number of people with diagnosed dementia across North East Lincolnshire could rise from about 920 to 1700 over the same ten year period.
Without implementation of the local strategy there would be increased recurrent costs for health related spend of c. £0.7m by 2015/16 and c. £1.5m by 2020/21; for social care related spend the equivalent figures are c. £0.94m and c. £1.8m respectively.
Increasing diagnosis rates and compliance with NICE Guidance will result in an increase in the prescribing of Alzheimer’s drugs over the ten year period with an associated cost increase. These drugs have recently come off licence with significant cost reductions. This means that the costs of increased usage will be largely offset by the price reduction.
The table below illustrates the impact of demographic growth and the increase in the projected number of people with dementia in North East Lincolnshire on resource usage if NEL had not commenced implementation of its dementia strategy and invested in services. The figures show the change in recurrent spend from 2011/12 baseline for the three years 2013/14, 2014/15, 2015/16 and then 2020/21. They indicate that 2020/21 costs (at current prices) would have increased across health and social care related spend by c£3.3million per annum.
This increase is most marked in care home placements and general hospital admissions.
The CCG has commissioned services specificly for people with dementia in an attempt to integrate health and social and third sector services to improve patient experience through better communication, reduced workloads and generally working together to deliver good outcomes for people with dementia and their carers. The following services are currently being commissioned, but it should be recognised that the challenges and cost pressures and rising demand will need to be met in the future.
Generic care homes for people with dementia in the low to moderate dementia category. All provision in NEL is provided by the independent sector, either commissioned by the CCG or by those who buy their services directly (self funders). Continuing healthcare placements are funded by the NHS (as opposed to being funded from adult social care budgets).
Residential care places that outside of the NEL area;
Places funded by the NHS, as noted above
Domiciliary Home Care
The biggest pressure point, at a time of increasing personalisation and volume pressures within older people’s care and care of those with dementia, is currently within the domiciliary care sector. An increase in demand for domiciliary care has been reflected in the increasingly complex packages, with more double up calls needed.
Enhanced Dementia Care
Grimsby Grange Enhanced dementia unit 15 beds
Haverstoe Enhanaced dementia unit 11 beds
Cranwell Enhanced dementia unit 12 beds commissioned /5 private funded
Cranwell Enhanced shared care and Assessment ( short term)8 beds
12 day places for people with more complex needs in the enhanced care unit Cranwell
There are no dementia nursing care homes in NEL.
As noted earlier, the CCG is seeing an increase in the proportion of people with dementia, in both residential and nursing homes, and this trend is expected to continue. The CCG offers a higher weekly rate for providers delivering enhanced dementia care, which recognises the additional costs that can be involved in delivering quality care for people with dementia.
Making an informed choice – we are aware that improvements are needed in helping people with dementia to make the best decision about moving into a care home, with people often making a choice in a very short space of time and often when they are in hospital. Good access to information can help them make a choice, in their own time, ideally as part of a planned process rather than in response to a crisis.
From consultation with older people we know that "Extra Care" models of housing are in demand and that the current provision in NEL falls short of requirements. The CCG has commissioned extra care schemes which will provide some opportunity for people with dementia to apply for accommodation within these settings. The CCG's first Extra Care Housing scheme launched in 2015 at Strand Court, Grimsby, and has been fully allocated. Although further schemes are in development, there is a shortage of different tenure models to meet the needs of people with dementia.
Preventative services within the community
A significant amount of our community investment is targeted at daytime activities to address social isolation for older people.
Through Alzheimer’s society contract and various community projects:
- Dementia advisors within primary care and memory services
- Dementia café’s
- Singing for the Brain
- Sports reminisce
- Improving sleep project
- Tea dances
- MYLife person centred care
- Developing dementia friendly community in NEL
- Befriending and community support – Friendship at Home
specialist dementia services- NAVIGO:
Home treatment service
Memory support service
Hospital and care home liaison team
10 inpatient beds
Admiral nurse service
Huntington’s nurse services
Person centred care team
Crisis response team out of hours
In addition to this the CCG has commissioned:
Care Plus Group mental health integrated dementia workers
focus independent adult social work integrated case workers
Training-Dementia champions x 60 and Ambassadors x 24 within all care services provided by NEL.
Future demands and needs
Future demands will be driven by the expected increase in the over 65 age group in NEL which is predicted to increase by 38% by 2025 and this indicates an increase of 52% in the incidence of dementia. North East Lincolnshire has already made significant investment and progress in implementing the National Dementia Strategy (NDS).
The CCG commissioned some work with the Whole Systems Partnership using the NDS Implementation Simulator. The Implementation Simulator is a modelling tool that reflects the main underlying demographic drivers for need in a given population of people with dementia together with the impact on capacity and costs that result from NDS implementation has provided a detailed understanding of how it operates and recommended further developments of services as follows;
Improved awareness - people receiving a diagnosis and the vitally important role GPs play is critical, as this is seen as the route to people with dementia and their carers being in touch with and accessing services. Increasing awareness should result in more referrals for assessment, and thus increased rates of diagnosis. There is a well-established and accredited memory assessment service already in place in NEL which has received significant investment.
Based on the identified level of ambition for NEL memory assessment, by 2016 there would be c 1420 people with a diagnosis of dementia compared with c1035 currently.
Community support - the number of additional CMHT contacts per week resulting from this increase could be 38. To combat this there is a need to explore the potential for some people to be supported outside of the specialist service, subject to appropriate support being available for those with diagnosed dementia who do not require specialist support.
In light of the substantial investment in memory assessment the ambition for the percentage of people diagnosed could be increased within existing resource working with local GPs for referral for assessment and thus access to services.
Specialist crisis response service - closer working/ integration between services to prevent duplication, maximising the use of resources and ensuring people with dementia receive the support required to best meet their needs (physical / mental health / social). Pragmatic solutions to streamlining the flow of patients to the right service first time building on the services already in place that creates an integrated and seamless service for the patient.
There will be an increased pressure for community support of around 60 people per annum by 2016 as a result of diversion from long stay admission to general hospital by the liaison team.
Integrated team providing intensive support- home care and treatment function focusing on preventing institutional placements. There are a number of teams in place and that the answer lies in integration / closer working of these rather than creating something new.
Carer Support- this is a vital area to prevent carer breakdown and avoid hospital and care home admission. Further developments are proposed and the work of the CCG in investing in the third sector and supporting communities and groups to grow their own capacity by providing start-up funds to tap into resources earmarked for carers outside of the dementia budgets to maximise the resource and services available to carers.
There are currently in the region of 226 carers per annum of people newly diagnosed with dementia and that this figure will rise to around 267 by 2016.
The overall vision for dementia care in North East Lincolnshire is being driven by the shared vision with North Lincolnshire CCG linked to Healthy Lives, Healthy Futures. The effects of this for those with dementia will be to offer alternatives to hospital admission whenever possible, by ensuring that community based services are configured correctly. Meeting demand through choice and control to support a culture of independence, increasing options and opportunities by delivering services closer to home.In particular services that support people with dementia in the last stages of life who are more likely to receive an inpatient stay.
Commissioning principles and aims, including timings for any significant developments in commissioning
Market management will be supported through our Public Health partners, who will advise and indicate trends and demographic changes. Meeting demands through choice and control to support a culture of independence, increasing options and opportunities by delivering services closer to home. Adult Social care is also working closely with our current and potential providers to ensure choice within the social care market, including the third sector.
The CCG will commission services to:
- Place an emphasis on prevention and early intervention, to help people remain independent and to reduce the demand on acute services
- Promote health and well-being in the widest sense, helping people to have greater control of the services they need, and supporting them to have more responsibility for the management of their own conditions/ situation
- Support models of social care provision that are co-productive - ie, where users and professionals work together to design and deliver public services in equal partnership, encouraging people who use services, people who provide services and people who commission services to work co-operatively to deliver the best outcomes and establish sustainable support systems.
The NHS is influenced by NICE guidance and the national Public Health Strategy. GP led NHS commissioning will gather momentum as Clinical Commissioning Groups develop. The Care Act 2014 reinforces previous Government messages about independence and community capacity.
Provider implications - how the CCG expects the market to respond
We aim to facilitate more individual choice, enterprise and less dependency on traditional services. We are taking forward an approach that is based on:
- Encouraging greater well-being, self reliance, autonomy and personal responsibility
- Co-production: building on existing community assets and unlocking social capital
- Seeking innovation and supporting community led models that are alternatives to traditional social care options
- Plurality in the market: exploring new models including partnership, user led organisations, and social enterprises
- Considering overall value, including economic, environmental and social value
- Localism and devolution: handing more power and responsibility back to communities to enable people to run their affairs locally
- Philanthropy: altruistic giving and exchange demonstrated in volunteering and time banking that not only add to community resilience but can also be a pathway for skills development and paid work.
Quality and perfomance monitoring
Outcome based specifications are being introduced to all newly commissioned services, and through the process of contract review, will be introduced to all existing services that incorporates the service user experience. The NEL Quality framework will ensure that care homes and other services deliver a high quality of dementia care . Contract performance will be measured through Key Performance Indicators to ensure that providers are meeting the expectations of the service specification and contract. This data will be analysed and issues discussed directly with the provider regarding plans to mitigate risks; the provider will be required to provide an action plan to address identified risks. Where risks cannot be managed and there is significant risk to service user/ patient care and service delivery, discussions may include the option to decommission the service. Where possible, every effort will be made to work with the provider to ensure continuity of service delivery.
Wherever possible tender procedures have and will continue to include services users and community members to guide the tender process and choice of provider to win the tender. The CCG will ensure that the Any Qualified Provider procurement model will reduce barriers to entry for potential providers, and so improve patient choice and access, and deliver value for money.