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National Dementia Strategy for England – update for ADI. Sube Banerjee Professor of Mental Heath and Ageing, The Institute of Psychiatry, King’s College London. Bringing it home, the local case - Dementia UK Report simple messages – common and costly. Population prevalence (%) of dementia

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National dementia strategy for england update for adi l.jpg

National Dementia Strategy for England – update for ADI

Sube Banerjee

Professor of Mental Heath and Ageing, The Institute of Psychiatry, King’s College London


Bringing it home the local case dementia uk report simple messages common and costly l.jpg
Bringing it home, the local case - Dementia UK Report simple messages – common and costly

Population prevalence (%) of dementia

by age

  • Numbers with dementia700,000

    In 30 years – doubling to 1.4 m

  • UK dementia cost - £17billion pa

    In 30 years – tripling £51billion pa

Knapp et al (2007)


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Dementia UK Report simple messages – under-recognised, under-treated

Variation in treatment and diagnosis of

dementia in the UK

Variation in treatment and diagnosis of

dementia across Europe

24x variation


National dementia strategy england l.jpg
National Dementia Strategy - England under-treated

  • Published 2 Feb 2009

  • Five year plan

  • 17 interlinked objectives

  • £150 million extra funding

  • Three key themes

  • Improving awareness

  • Early and better diagnosis

  • Improved quality of care

    • Also Delivering the Strategy






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The fundamental problem - now attitudes and understanding

  • Only a third at most of people with dementia receive any specialist health care assessment or diagnosis

  • When they do, it is:

    • Late in the illness

    • Too late to enable choice

    • At a time of crisis

    • Too late to prevent harm and crises


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The solution attitudes and understanding

  • 80% of people with dementia receive specialist health care assessment or diagnosis

  • When they do, it is:

    • Early in the illness

    • Early enough to enable choice

    • In time to prevent harm

    • In time to prevent crises


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Services for early diagnosis and intervention in dementia for all

  • Working for the whole population of people with dementia

    • ie has the capacity to see all new cases of dementia in their population

  • Working in a way that is complementary to existing services

    • About doing work that is not being done by anybody

  • Service content

    • Make diagnosis well

    • Break diagnosis well

    • Provide immediate support and care immediately from diagnosis

Banerjee et al 2007, IJGP



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Theme 3 - Improving quality of care for all

  • O6. Improved community personal support services

    • generic and specialist – collation of data

  • O7. Implementing the Carers’ Strategy for people with dementia

    • make it work for dementia

  • O8. Improved quality of care for dementia in general hospitals

    • clinical leads for dementia, specialist liaison teams – collation of data

  • O9. Improved intermediate care for people with dementia

    • change in guidance

  • O10. Housing support, related services and telecare

    • watching brief

  • O11. Living well with dementia in care homes

    • including review of use of antipsychotic medication in dementia

  • O12. Improved end of life care for people with dementia

    • making it work for dementia


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Living well with dementia in care homes for allReduced use of antipsychotic medication


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Ministerial review of use of antipsychotics in dementia for all

  • Published November 2009

  • Comprehensive review

    • Negative effects

    • Positive effects

  • Analysis of reasons for current clinical behaviour

  • Practical clinical plan to deal with problems found


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1,098,627 patients 12-month period from 1 April 2007 to 31 March 2008.

10,255 (5.3%) received a prescription for an antipsychotic

Estimates for the report

25% people with dementia receiving an antipsychotic

180,000 people with dementia receiving an antipsychotic

Treat 1,000 people with BPSD with an atypical antipsychotic for 12 weeks:

91–200 patients with clinically significant improvement

an additional 10 deaths;

an additional 18 CVAEs,

around half of which may be severe;

For UK

1,800 deaths per year

1,620 severe CVAEs per year

Summary of risks and benefits at a population level of the use of atypical antipsychotics for BPSD in people with dementia


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Analysis of why March 2008.

  • Symptom of underlying system failure in health and social care for people with dementia

  • 1960s response to a 21st century challenge

  • Why lack of response to clear warnings

    • It is complicated

    • System does not allow change

      • Knowledge

      • Attitudes

      • Provision

  • Simple stuff eg specialists shouting at GPS does not work

  • Need to treat the cause as well as the symptoms


  • Action l.jpg
    Action March 2008.


    What happened next l.jpg
    What happened next… March 2008.

    • Not a lot…


    What makes things happen l.jpg

    What makes things happen? March 2008.

    commissioning


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    Operating Framework 2008/9 March 2008.

    ‘dementia:

    providing people with dementia and their carers the best life possible is a growing challenge, and is one that is becoming increasingly costly for the NHS. Research shows that early intervention in cases of dementia is cost-effective and can improve quality of life for people with dementia and their families. The Department will shortly be publishing details of the clinical and economic case for investing in services for early identification and intervention in dementia, which PCTs will want to consider when developing local services ’


    Operating framework 2008 922 l.jpg
    Operating Framework 2008/9 March 2008.

    ‘dementia:

    providing people with dementia and their carers the best life possible is a growing challenge, and is one that is becoming increasingly costly for the NHS. Research shows that early intervention in cases of dementia is cost-effective and can improve quality of life for people with dementia and their families. The Department will shortly be publishing details of the clinical and economic case for investing in services for early identification and intervention in dementia, which PCTs will want to consider when developing local services ’


    Operating framework 2009 10 l.jpg

    60. There have been a number of important developments in the last year within the context of High Quality Care for All that will help PCTs determine how they develop and implement their local plans. These cover the following areas:

    alcohol;

    dementia;

    end of life care;

    mental health;

    military personnel, their dependants and veterans;

    mixed-sex accommodation;

    people living in vulnerable circumstances; and

    people with learning disabilities.

    62. The National Dementia Strategy will be a comprehensive framework aimed at driving up standards of health and social care services to improve the quality of life and quality of care for people with dementia and their carers. PCTs will want to work with local authorities to consider how they could improve dementia services.

    3.30 Nationally, there is a range of tools to assist PCTs and specialised commissioning groups in delivering their priorities as world class commissioners. These include, but are not limited to: the developing National Support teams(NST) for health inequalities, tobacco, alcohol, infant mortality, teenage pregnancy, sexual health, vaccinations and dementia…

    Operating Framework 2009/10


    Revision to the operating framework for the nhs in england 2010 11 l.jpg
    Revision to the Operating Framework for the NHS in England 2010/11

    • One of only two new specific priorities

    • 13. During the recent sign-off of SHAs plans, two areas stood out as not being given sufficient emphasis. The first is ensuring that military veterans receive appropriate treatment… The second area is dementia. NHS organisations should be working with partners on implementing the National Dementia Strategy. People with dementia and their families need information that helps them understand their local services, and the level of quality and outcomes that they can expect. PCTs and their partners should publish how they are implementing the National Dementia Strategy to increase local accountability for prioritisation.


    Revision to the operating framework for the nhs in england 2010 1125 l.jpg
    Revision to the Operating Framework for the NHS in England 2010/11

    • One of only two new specific priorities

    • 13. During the recent sign-off of SHAs plans, two areas stood out as not being given sufficient emphasis. The first is ensuring that military veterans receive appropriate treatment…The second area is dementia. NHS organisations should be working with partners on implementing the National Dementia Strategy.People with dementia and their families need information that helps them understand their local services, and the level of quality and outcomes that they can expect. PCTs and their partners should publish how they are implementing the National Dementia Strategy to increase local accountability for prioritisation.


    Slide26 l.jpg
    Quality outcomes for people with dementia: building on the work of the National Dementia Strategy (DH, 2010)

    ‘There are four priority areas for the Department of Health’s policy development work during 2010/11 to support local delivery of the Strategy. These areas provide a real focus on activities that are likely to have the greatest impact on improving quality outcomes for people with dementia and their carers. It is important to emphasise however that the priorities are enablers for local delivery of the Strategy in full, across all 17 objectives, as well as the work to implement the recommendations of the report in to the over-prescribing of antipsychotic medicines to people with dementia.

    The four priority areas are:

    • Good quality early diagnosis and intervention for all - Two thirds of people with dementia never receive a diagnosis; the UK is in the bottom third of countries in Europe for diagnosis and treatment of people with dementia; only a third of GPs feel they have adequate training in diagnosis of dementia.

    • Improved quality of care in general hospitals - 40% of people in hospital have dementia; the excess cost is estimated to be £6m per annum in the average General Hospital; co-morbidity with general medical conditions is high, people with dementia stay longer in hospital.

    • Living well with dementia in care homes - Two thirds of people in care homes have dementia; dependency is increasing; over half are poorly occupied; behavioural disturbances are highly prevalent and are often treated with antipsychotic drugs.

    • Reduced use of antipsychotic medication - There are an estimated 180,000 people with dementia on antipsychotic drugs. In only about one third of these cases are the drugs having a beneficial effect and there are 1800 excess deaths per year as a result of their prescription.’


    Slide27 l.jpg
    Quality outcomes for people with dementia: building on the work of the National Dementia Strategy (DH, 2010)

    ‘There are four priority areas for the Department of Health’s policy development work during 2010/11 to support local delivery of the Strategy. These areas provide a real focus on activities that are likely to have the greatest impact on improving quality outcomes for people with dementia and their carers. It is important to emphasise however that the priorities are enablers for local delivery of the Strategy in full, across all 17 objectives, as well as the work to implement the recommendations of the report in to the over-prescribing of antipsychotic medicines to people with dementia.

    The four priority areas are:

    • Good quality early diagnosis and intervention for all - Two thirds of people with dementia never receive a diagnosis; the UK is in the bottom third of countries in Europe for diagnosis and treatment of people with dementia; only a third of GPs feel they have adequate training in diagnosis of dementia.

    • Improved quality of care in general hospitals - 40% of people in hospital have dementia; the excess cost is estimated to be £6m per annum in the average General Hospital; co-morbidity with general medical conditions is high, people with dementia stay longer in hospital.

    • Living well with dementia in care homes - Two thirds of people in care homes have dementia; dependency is increasing; over half are poorly occupied; behavioural disturbances are highly prevalent and are often treated with antipsychotic drugs.

    • Reduced use of antipsychotic medication - There are an estimated 180,000 people with dementia on antipsychotic drugs. In only about one third of these cases are the drugs having a beneficial effect and there are 1800 excess deaths per year as a result of their prescription.’


    Dh commissioning packs landsley 2010 l.jpg
    DH commissioning packs (Landsley 2010) work of the National Dementia Strategy (DH, 2010)

    Commissioning packs are tools to help commissioners improve the quality of services for patients, through clearly defined outcomes that help drive efficiency by reducing unwarranted variation in services.

    • Each pack contains a set of tailored guidance, templates, tools and information to assist commissioners in commissioning healthcare services from existing providers, or for use in new procurements.

    • Integral to each pack is an evidence-based service specification which ensures that patients are placed at the forefront of the service and are central to decisions about their care.

    • The specification is non-mandatory and can be adapted to reflect local needs and once agreed with the provider should inform part of a renegotiated contract or form the relevant section of the NHS standard contract.

    • By bringing together the clinical, financial and commercial aspects of commissioning in one place, the packs simplify processes and minimise bureaucracy.  

      1. Cardiac rehabilitation – Oct 2010

      2. Dementia – March 2011

      3. Chronic obstructive pulmonary disease


    Money clinical cost effectiveness l.jpg

    Money work of the National Dementia Strategy (DH, 2010)clinical/cost effectiveness


    Early intervention for dementia is clinically and cost effective spend to save l.jpg
    Early intervention for dementia is clinically and cost effective – “spend to save”

    • 215,000 people with dementia in care homes -- £400 per week

    • Spend on dementia in care homes pa

      • £7 billion pa

    • 22% decrease in care home use with early community based care

    • 28% decrease in care home use with carer support (median 558 days less)

    • Quality – older people want to stay at home, higher qol at home

    • Take an additional 220 million pa

    • Delayed benefit by 5-10 years

      • Strategic head needed

    • Model published by DH

    • 20% releases £250 million pa y6


    Cost effectiveness l.jpg
    Cost effectiveness effective – “spend to save”

    Please ignore – not English - economics

    • The Net Present Value would be positive if benefits (improved quality of life), rose linearly from nil in the first year to £250 million in the tenth year. This would be a gain of around 6,250 QALYs in the tenth year, where a QALY is valued at £40,000, or 12,500 QALYS if a QALY is valued at only £20,000.

    • By the tenth year of the service all 600,000 people in England then alive with dementia will have had the chance to be seen by the new services

    • A gain of 6,250 QALYS per year around 0.01 QALYs per person year. A gain of 12,500 QALYS around 0.02 QALYs per person year.

    • Likely to be achievable in view of the rise of 4% reported from CMS.

    • Needs only:-

      • a modest increase in average quality of life of people with dementia,

      • plus a 10% diversion of people with dementia from residential care, to be cost-effective.

    • The net increase in public expenditure would then, be justified by the expected benefits.

    Banerjee and Wittenberg (2009) IJGP


    Success in quality improvement in dementia requires l.jpg
    Success in quality improvement in dementia requires effective – “spend to save”

    • Vision

    • System change

    • Ambition in scale

    • Investment

    • Commitment over time

    • Leadership


    Thank you l.jpg

    Thank you! effective – “spend to save”


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