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The term ‘dementia’ describes a set of symptoms that include;

These symptoms occur when the brain is damaged by certain diseases, such as Alzheimer’s disease, a series of small strokes or other neurological conditions such as Parkinson’s Disease.   

Around 60% of people with dementia have Alzheimer’s disease, which is the most common type of dementia, around 20% have vascular dementia, which results from problems with the blood supply to the brain and many people have a mixture of the two. There are other less commons forms of dementia, for example dementia with Lewy bodies and fronto-temporal dementia. 

Dementia is a growing challenge, as our population continues to age. After the age of 65, the chances of developing dementia doubles every five years. We need to continue to focus on this area as dementia has, and will continue to have, a huge impact on people living with the condition, their carers, families and society more generally. 

Locally, our CCG is performing well in diagnosing people who have dementia and making sure that these people are recorded on GP registers. We want to build on this good work to make sure that there is equitable access to treatment and services for dementia. We are also looking at how we can improve support and treatment for those post-diagnosis. This involves working with our local partners, including Bradford District Care NHS Foundation Trust and the local authority to redesign and transform services. 

The term 'delirium' describes a set of symptoms that include:

Delirium is a condition where people have increased confusion, chanegs in thinking and a reduced attention span. Symptoms can develop quickly and often fluctuate during the day. Delirium is also known as 'acute confusion'. It is curable - but if it is undetected then it can be a life-threatening condition.

How are we doing?

Our data shows that our CCG is performing in the best quartile in the country for diagnosing dementia. 

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Strategy

The Bradford and Airedale dementia strategy, 2015-2020  aims to reduce the impact of dementia and help improve care for those with the illness. The five key aims of the strategy are to:

  • keep people with dementia in their homes for as long as possible,
  • increase the focus on dementia in care homes,
  • increase awareness of prevention of dementia through healthy lifestyles
  • enable the provision of high quality end of life care for people with dementia
  • enable people to live well with dementia

Needs assessment

Following the 2014 district-wide dementia needs assessment we are working on improving the whole patient experience around dementia - from preventing the onset of the condition to post-diagnostic support - using the dementia well pathway

 

Healthy lifestyle

Having a healthy lifestyle is good for the brain and the heart. Two of the biggest health issues in Bradford are heart disease and Type 2 diabetes, and therefore we have continued to promote the benefits of living a healthy lifestyle to our local population through our Bradford Beating Diabetes and Bradford’s Healthy Hearts programmes. 

Diagnosis

Our CCG is performing well with a dementia diagnosis rate of 9.2%. 80% of outpatients with a diagnosis of dementia have a care plan in place.

Review of memory assessment services

There has been a formal review of the pathway from referral to diagnosis in our three memory clinic teams to ensure that all patients are able to access a diagnosis and the appropriate care planning. The review has shown that our diverse population does require different approaches to access and engagement and this work will continue as we work towards the planned targets in the evidence-based treatment pathway.

Post-diagnostic support services

We are still looking at the re-procurement of our post diagnostic services to ensure that they are accessible and appropriate for our population. 

Care planning in face to face reviews

We have delivered high quality education and training and have developed accessible resources to support meaningful care planning reviews in primary care.

Recognition of patients with dementia in care homes

We continue to support the roll out of the nationally recognised DiADeM tool (Yorkshire and Humber diagnosis of advanced dementia mandate) in our care homes to support the diagnosis and care planning of our care home population.

Becoming dementia friendly

Many of our GP practices are now dementia friendly and we are continuing to support other services we commission to become dementia friendly too. Our aim is to make sure that as a city, Bradford is dementia friendly.

Prevalence - estimated diagnosis rate for people with dementia

Our CCG has identified 94.2% of patients who are expected to have dementia. This is in the top quartile of the country for dementia diagnosis,

19/20 people who are expected to have dementia have been diagnosed. 

What we are doing to continue to maintain and improve the diagnosis of dementia

We have worked with Bradford District Care NHS Foundation Trust (BDCFT) to review the pathway for memory assessment and treatment services (MATS), following which additional resources have been provided. The service is also looking at how to improve efficiency to maximise the use of resources and implement best practice.  We have worked with BDCFT to increase the level of support available to people recently diagnosed with dementia, their families and their carers.  We want to maintain a diagnosis rate of over 75% of the estimated number of people with dementia in 2017/18. We are performing well in relation to the dementia diagnosis

Care planning and post-diagnostic support

80% of patients who have been diagnosed dementia have had a review in the lats 12 months. Our CCG is in the second highest quartile nationally for care planning and post-diagnostic support, indicating that we are performing well.

What we are doing to support our GP practices with face-to-face reviews

We have developed resources for our GP practices so that they can better support patients. This includes a care planning and education package to support them when doing annual dementia reviews and signposting to an appropriate service. For patients, we have developed a leaflet entitled What makes a difference? which helps them prepare for their appointment with a nurse/GP and helps them to think about the issues that are most important to them. The Bradford advanced care plan booklet helps patients plan their care and ensure that patients, their family and carers are supported in deciding what care they want for the future.

What you have told us about dementia services 

We make sure that we are listening, engaging and involving patients in the planning and design of their local NHS. To do this, each programme of work has the infrastructure to engage and collect information from people through:

Dementia service experience

The insight and feedback you give us makes sure that we don't just collect information, but that we have the means and ability to use it to inform our commissioning activity and improve quality. All the insight and feedback is pulled together in a system we call Grass Roots.

Grass Roots

Grass Roots pulls together information reported through NHS Choices, Patient Opinion, Healthwatch, complaints, local groups and direct patient, family and community feedback so that we can understand experiences of local NHS services. This information helps us inform our CCG planning and decision making. 

Dementia - grassroots

Patient stories

Our CCG has funded the localisation of a website dedicated to supporting carers of those living with dementia. The Dementia Carer website has lots of videos from Bradford people who are careres of those living with dementia. These videos capture their experiences of services and other aspects of daily life living with dementia. 

What did we do in 2016/17?

During 2015/16 we worked with our local partners, including Bradford Council, to develop the Bradford and Airedale dementia strategy, 2015 – 2020.

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Dementia strategy

The Bradford and Airedale dementia strategy, 2015 – 2020 aims to reduce the impact of dementia diagnosis and help improve care for those diagnosed, their families and their carers. It also provides a clear district-wide plan of action with five key aims;

  • enable people living with dementia to stay in their homes for as long as possible,
  • increase the focus on dementia in care homes,
  • increase awareness of the benefit of a healthy lifestyle to prevent dementia,
  • enable the provision of high quality end of life care for people with dementia, and,
  • enable people to live well with dementia.

Support for carers of those living with dementia

In 2015 we supported the localisation of the Dementia Carer website. The website is aimed at carers of people living with dementia. It provides advice and support, details of local services and groups, and information about the condition. We have also funded a targeted local communications campaign to raise awareness of the website amongst the relevant groups. 

We have also commissioned Carer's Resource which provides a support service for carers, including of those caring for people living with dementia, across Bradford, Airedale, Wharfedale and Craven. 

Development of memory assessment and treatment services

We have worked with Bradford District Care NHS Foundation Trust to review the pathway for memory assessment and treatment services. Additional resources have been made available to support the memory assessment and treatment services at the trust. The service is also looking at how to improve efficiency to maximise the use of resources and implement best practice. 

We have also worked with Bradford District Care NHS Foundation Trust to increase the level of support available to people recently diagnosed with dementia, their families and their carers.

Care planning and support package

We have developed resources for our GP practices so that they can better support you. This includes a care planning and education package to support your GP practice when doing your annual dementia review and sign post you to appropriate service. 

For you, we have developed 'what makes a difference'. This leaflet helps you prepare for your appointment with your nurse / GP and think about the issues that are most important to you. TheBradford advance care plan booklet has also been developed. This helps you plan your care and ensure that you, your family and carers are supported in deciding what care you want for the future. 

Our plans for the next two years 

We are reworking our dementia strategy to make sure it continues to be relevant to the changing health and social care economy. Within this there will be a focus on delirium. We will work with local providers to ensure an increased focus on the recognition, prevention and treatment of delirium.

We are also working towards implementation of the evidence based treatment pathway. More GP practices are becoming “dementia friendly.”

The three CCGs (Bradford City, Bradford Districts and Airedale, Wharfedale and Craven) continue to work with the Yorkshire and Humber Dementia Clinical Network to produce the DiADeM Clinical tool to support the diagnosis of dementia in the care home setting. We will be using this in conjunction with the nationally recognised DeAr GP tool and in Bradford, our local incentive scheme for GPs to find our 'hidden patients' in the care home setting. We will be continuing our GP / primary care education and awareness sessions to ensure our clinicians are engaged in diagnosing and supporting patients and their carers to receive a diagnosis and access post diagnostic support.

We are also working with our local memory services provider and undertaking a mapping and improvement programme to ensure that the service is working towards the new expected access and waiting time targets due to be released in 2018. This will ensure the service has the resilience to cope with increased referral rates that may be a consequence of awareness raising amongst our clinicians.

The lead clinician for the two Bradford CCGs has also been instrumental in developing a local and regional set of resources for primary care (which has been cited on the National Dementia Care planning document due to be released in  2018).

All three CCGs are actively promoting dementia friendly communities and engaging with GP practices, other NHS organisations and the voluntary sector to increase awareness and uptake of the initiative. One of our GP practices is leading the way in being dementia friendly and is also supporting other practices. We will also be working via our contracting procedures with providers to ensure they are dementia friendly and consider the needs of people with dementia and their carers.

The CCGs have also commissioned a wesite - www.dementiacarer.net - which supports all carers in our population to find support and self-care. 

The CCG and Bradford Council are working together to review the post diagnostic support offer for patients with dementia in 2017/2018. In North Yorkshire we are supporting the development of the dementia strategy which is due to launch in 2017.

Our plans for the next five years 

Over the next five years, we plan to build on the strong foundation that we have already developed for people living with dementia, their families and their carers.  

Our vision:

Dementia - the next five years

To achieve this vision, we will be looking at two main areas:

Improving care and quality of services

There are a number of measures that we will be taking to improve care for people living with dementia:

Creating a 24/7 integrated system across health and care

The Better Care Fund is enabling us to make a significant change in the capacity and capability of community services. Our ambition is for these community services to become an integrated 24/7 system. This is extensive work which includes delivering: