MIDLOTHIAN COMMUNITY CARE

PARTNERSHIP

Dementia Demonstrator Site

Jane FairniePlanning Officer

MidlothianMidlothian is the second smallest local

authority area in Scotland. It adjoins Edinburgh’s southern boundary, and is

framed by the Pentland Hills in the west and the Moorfoot Hills of the Scottish

Borders in the south. Most of Midlothian’s population, of around 80,000, resides in or

around the main towns of Penicuik, Bonnyrigg, Loanhead, Dalkeith,

Newtongrange and Gorebridge. The southern half of the authority is still

predominantly rural, with a small population spread between a number of

villages and farm settlements.

Midlothian• The General Registers of Scotland predicts that the population of Midlothian will decrease by approximately 1,256 people by the year 2020. This estimate, however, does not take into account planned new housing developments

•The 60+ age groups are growing in comparison with the rest of the population. Midlothian will soon have more pensioners than children

• In 2009/10 – 588 people with diagnosis of dementia on QOF register• In 2010/11 – this had risen to 637

The project will seek through a whole systems approach, to develop community based services which reduce reliance on long stay care homes and continuing care beds and minimise admissions to acute hospital

OBJECTIVES OF THE MIDLOTHIAN PROJECT

Developing a better understanding of users’ experience of services through IRF mapping and through user/carer consultation to influence the redesign

Delivering stronger integrated care pathways for people with dementia to streamline and speed up access to services.

Promoting a joint approach to the allocation of resources between NHSL and the Council to support people with dementia more effectively

Promoting “Shifting the Balance of Care” for people with dementia through stronger integrated working across health, social work and the wider community

OBJECTIVES OF THE MIDLOTHIAN PROJECT

Service mapping in all services across Health, Social Work and Third Sector completed using SWOT analysis to audit services against the Standards of Care for Dementia in Scotland, and data now being collated

Examples of initial findings show gaps in areas of communication with people who live with dementia – staff don’t have knowledge of, or access to specialist communication tools, knowledge of legal framework such as POA, guardianship etc, knowledge of advocacy services, need for meaningful activity and involving carers in staff training

Examples of excellence found in end of life care, carer support, promoting independence and treating people with dignity and respect

Progress to date

Family Group Conferencing identified at a Stakeholders Event as a post-diagnostic support tool

Now being taken forward as a project Currently in research phase Visit planned early October to Hampshire’s “Daybreak”

project Based on the principle of “Family Solutions to Family

Problems” where families and close support networks take ownership of supporting the person with dementia thus reducing reliance and dependence on rigid and inflexible formal supports

Progress to date

Workforce Development Staff questionnaire currently out to all care and support

staff in Midlothian Aim is to benchmark current qualification, knowledge,

skills and understanding prior to rolling out any awareness raising and training programmes to measure the impact of that training – links to Promoting Excellence Framework

Funding roll out of training programme for Care at Home staff across Midlothian in all sectors through Stirling University and establishing Dementia Champions

Progress to date

GP engagement GP survey completed – positive suggestions for service

redesign locally GP sign-up to sharing QOF data for IRF mapping to

identify patient pathways

Progress to date

Narrative research into the lived experience of dementia from both the individual and the carer perspective

Being undertaken by Queen Margaret University with the Researcher now in post

6 month project involving semi-structured interviews and focus groups to explore how individuals make sense of experiences related to their condition, their attitudes toward those experiences, what meanings the events hold for them and how these meanings are created in the light of contextual and cultural factors

This research will enable the project team to further identify service gaps and barriers.

Progress to date

User/Carer survey being sent out in January 2012 To compliment the Narrative research Using a Talking Points model To identify what works well for people who live with

dementia and their carers and what has made their journey more difficult

Progress to date

IRF data mapping Part of the Lothian IRF Project Data from 08/09, 09/10 and 10/11 will be used to map

dementia pathways down to individual GP practice level Use of Caretrak software to analyse data All data will be ready for analysis by end 2011 IRF data will be used to measure cost savings at the end

of the project as part of the evaluation process

Progress to date

Service redesign will be predicated upon what people with dementia and their carers tell us will help make their journey smoother

Early indications from Stakeholder consultation suggest this may include

A single multi-disciplinary assessment, treatment and care management service

A Midlothian dementia toolkit to include a multi-disciplinary assessment and single care plan

A responsive and flexible dementia-friendly Home Care service which is not bound by rigid time slots

A local Dementia Working Group for Midlothian people

The Future

Further details on this work from

Jane Fairnie Jane.Fairnie@midlothian.gov.uk

Janice Flockhart Janice.Flockhart@nhslothian.scot.nhs.uk

Peter Haughey Peter.Haughey@midlothian.gov.uk

Workshops:

SWOT Analysis – auditing against the Standards

Family Group Conferencing – post diagnostic support

Find out more