section 6b - memory assessment and treatment services. final … wellbeing... · 2016-03-21 · !...
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Section 6 -‐ Memory Assessment and Treatment Services
Memory Assessment and Treatment Services (MATS) are recommended as the single point
of referral for those with a possible diagnosis of dementia (1). Providing a specialist diagnosis
service ensures that those with dementia have access to the full range of assessment,
diagnostic and therapeutic services to ensure a correct diagnosis of dementia is made and
that other medical causes of memory loss are considered.
In Bradford and Airedale, the MATS services are provided by Bradford District Care Trust and
are delivered within the localities of the provider Community Mental Health Teams which
include, Bingley and North Bradford, Bradford South and West, Bradford City and Airedale
and Craven. MATS services have been delivered across Bradford and Airedale since 2010,
and differing commissioning arrangements have resulted in a variety of models being
delivered.
Local MATS/ACHL Review 2013
In 2012 Bradford, Airedale and Leeds PCT successfully bid for funding to review the Memory
Assessment and Treatment services and the Acute and Care Home Liaison services provided
by Bradford District Care Trust (BDCT) across the localities of Bradford, Airedale and Craven.
The review aimed to identify an evidence-‐based model for equitable access to MATS across
the District and for the early detection and diagnosis of dementia via the Acute and Care
Home Liaison (ACHL) service to optimise financial and quality outcomes for people with
dementia. The services under review were considered within the context of the wider health
and social care system taking into account other relevant services and the potential impacts
of any future dementia service models.
It was agreed at the outset of the review that it would integrate with and be a key part of
this Health Needs Assessment and the authors of the review and the HNA worked closely
together to ensure this. The review was completed in June 2013, and includes the MATS and
ACHL service and the CMHT role and function in the provision of diagnostics for those with
dementia, covering the Bradford, Airedale and Craven localities. It is not the intention to
repeat the entirety of the review here, but to outline key highlights relating to MATS services
and those elements that are of particular relevance to this Health Needs Assessment. The
full review document is available at (2).
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Key Findings of Local MATS/ACHL Review 2013
Outcomes:
The desired outcomes measures from delivering an effective model of service would be;
• Reduction in Care Home admissions from baseline of 395 per annum.
• Reduction in people with dementia staying in hospital for over 63 days.
• Reduction in non-‐elective admissions from Care Homes.
• Reduction in overall admissions to acute care where dementia is primary diagnosis
• Reduction in the number of patients whose pathway from acute hospital is to a care
home placement where residence was previously in community.
• Increased rates of diagnosis of dementia linked to Quality Outcomes Framework
(QoF)
• Increase in early detection of dementia through improved recognition and diagnosis
Key findings:
• Not all the voluntary sector services were familiar with the MATS or the ACHL
services and how to access them.
• Pathways and access to ACHL especially out of hours were not clearly understood by
all the services including staff within the acute hospital setting.
• The importance of access to support networks for those with dementia and their
families and carers following diagnosis.
• The importance of services such as advocacy and the Alzheimer’s society for those
with little family support.
• The variation across the district in the types of statutory and voluntary services
available to those with dementia.
• The wellbeing cafe provides an important forum for carers to meet others in a
similar situation with access to much needed support and social interaction.
• For many people with dementia the cafes were their main or only social outing.
• A number of people with dementia and their carers who attended the cafe spoke of
the fun they had and the importance of the cafe in their lives.
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Local MATS Service Models:
Bingley and North Bradford
This is the only locality with additional funding for a bespoke clinic based model developed
to meet the expected demands in that sector of the city.
The service aims to provide a seamless pathway of care which includes a full range of
assessment, diagnostic, therapeutic and rehabilitation services. Clinics are delivered in
primary care settings with the purpose of being accessible to all and outside the current
mental health services to reduce the stigma associated with dementia and old age
psychiatry.
The clinics provide a one-‐stop shop with as much as possible done at the first clinic
appointment to reduce waits and improve the patient’s experience. Patient and carers are
given defined time lines for further investigations (i.e. CT and MRI scans)
The integrated team includes community psychiatric nurses, psychiatrist input, occupational
therapist, dementia care advisor and access to social worker and a family support worker.
Approximately 25% of people are seen by the CMHT based occupational therapist. There is
identified admin time to support the planning of the clinics.
Every effort is made in ensure continuity of contact with staff but at times the need to
provide cover for staff absences results in service users and carers seeing different staff.
Home visits are available with approximately 5% of patients seen in their own homes.
Bradford South and West
South & West meets the growing demand for MATS services within the Community Mental
Health Teams (CMHTs) alongside all other aspects of their work.
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All referrals into the team are triaged to determine suitability for the MATS work stream,
once referred to the clinic there is access to assessments with both a psychiatrist and an
assistant clinical psychologist; occupational therapy input can be accessed via the CMHT.
For those with a dementia diagnosis and where medication has been prescribed, titration of
medication is carried out by a psychiatrist in clinic, and is followed 3 months later by a
review at the patient’s home by a mental health nurse accompanied by a worker from the
Alzheimer’s society if requested by the carer.
Inherent within this model is the expectation that there will be consistency in staff, so that
the doctor that completes the initial assessment will be the same as the doctor that breaks
diagnosis and titrates any medication prescribed.
Bradford City
The Bradford City MATS service takes referrals from any health professional and is
predominantly a clinic based service with around 25% of visits taking place in the home.
The model provides culturally sensitive services providing access to culturally modified
versions of cognitive assessment tools, staff with language skills and interpreters.
Assessments and diagnostics are carried out by medical staff with follow up appointments
offered 4-‐6 weeks later to review medication and offer on-‐going support to those with a
dementia diagnosis.
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Airedale
Referrals go directly to the CMHT Consultant Psychiatrist for a MATS assessment; all service
users are offered the option of having a MATS assessment in a clinic or within the home
setting.
The initial dementia assessment is carried out by the Consultant psychiatrist, a follow up
appointment is arranged soon after and involves a home visit from a member of the CMHT
and this is followed up by a 3 monthly medical review for those on medication followed by
discharge if there are no complications.
The integrated team includes community psychiatric nurses and consultant psychiatrist
input, there is no psychology provision and no direct involvement from the Alzheimer’s
Society.
Craven
Referrals into the CMHT are screened by the duty nurse and triaged to identify those
needing a MATS assessment; urgent referrals can be seen by a nurse within 10 days, those
needing an assessment are seen at home or in a clinic held at one of the following venues:
All referrals are assessed and diagnosed by the consultant psychiatrist; psychology input
from the CMHT is provided if there is doubt over the diagnosis or associated issues. Those
service users needing additional follow up support are discussed in the team meeting and
nurses arrange follow up appointments in the person’s home.
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There is no social worker available within the CMHT and social services are involved via
referrals to their main office in Skipton. There is no direct input from the Alzheimer’s Society
but people are asked if they wish to have support and are sign posted accordingly.
Measuring Services against Evidence-‐based Criteria
The MATS services were measured using the MSNAP 2010 criteria, from local commissioning
requirements and the views of service users and carers.
The identified gaps against the MATS evidence criteria;
• North and Bingley is the only locality to have a commissioned service with identified
additional resources to provide memory assessment services.
• There is no single agreed integrated pathway into MATS services.
• There has been no true consultation with those with dementia and their carers in
the development and planning of MATS services.
• The capacity of the clinics to make home visits varies from 5% in North & Bingley to
80% in Airedale.
• There is unequal access to psychology services with no psychology input into
Airedale and limited resources in the other localities.
• There is no neuro-‐psychology provision across the district.
• Airedale and Craven do not have Alzheimer’s Society staff available for face to face
contacts during clinics.
• Airedale, Craven and City do not have access to psychology assistants
• The services in South West and City are unable to see people within expected time
scales and have significant waiting lists for clinics.
The recommendations for the MATS services were:
1. To reduce the existing variation across localities it is recommended that existing
resources are deployed so that future services are developed more equitably with
access to a single integrated service.
2. That future MATS services are built on the 5 key stages framework providing a
consistent model across the district.
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3. Existing and additional funding resources are invested in modular building blocks
described in the review to build MATS capacity and build a service that is equitable
and able to meet local future demand. (These are explained in detail within the full
review report)
4. That the CCGs along with provider organisations develop a locality plan based on the
modular basis of service delivery with estimated demands and costs and for the
individual elements of a MATS service.
5. The referral process into MATS services is standardised to ensure that the referring
agency provides the appropriate information for effective triaging to MATS services
and specific requirements such as interpreters, home visits are identified.
6. All referrals in whatever format should be directed to the CMHT team and not to an
individual consultant to ensure that all referrals are triaged consistently and to
ensure a full MDT approach is considered.
7. Develop standard criteria for triage for MATS services with staff trained accordingly
to ensure there is a consistent process across all localities.
8. Resources available are deployed in a way that will ensure that variance in waiting
times is reduced. The Royal College of Psychiatrists MSNAP programme
recommends initial contact after referral to be 2-‐3 weeks and the assessment
process to begin no longer than 6 weeks from referral.
9. A standardised data set should be agreed by commissioners and providers and all
MATS services should report on a quarterly basis. This would enable a more
effective system of monitoring progress and trends across the CCG’s.
10. The high DNA in the city locality amongst MATS service users from BME
communities are audited to identify reasons and solutions are identified that result
in increased uptake.
Future models
Based on the national evidence base and existing provision of local MATS services there are
a number of key elements of a MATS service which need to be in place to deliver an
effective and comprehensive service. These are provision of a referral and triage process,
assessment, treatment, review and on-‐going support for the patient and their family.
It is proposed that any future model delivers the 5 stages as a basis for a service that
provides key functions and processes in line with the evidence base. From this base there
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are a number of options in how, where and with what resources the model can be built
upon and developed
These additional options provide ‘building blocks’ which can be added to the basic
framework to support the development of flexible, equitable and client based service which
meet the needs of those with dementia and their families and carers.
Rather than provide fixed models of MATS services for consideration the ‘building blocks’
below are presented with costs where possible and applicable. These can be considered
along with the 5 stage framework for the development of future services which are able to
deal with the increasing demands of the future and provide equity across the localities.
The 5 key stages of a MATS service are as follows:
1. Referral & Triage
2. Assessment
3. Treatment
4. Review
5. Ongoing support
Opportunities and Constraints of the two local MATS models
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Additional Data from the Health Needs Assessment
One of the key purposes of this Health Needs Assessment is to inform commissioning
strategy in respect of the issues raised in the 2012 review of MATS services. It is anticipated
that in early 2014 discussions will take place to this effect with the Health Needs Assessment
as a key reference.
In order to fulfill this purpose, this section of the report includes the following:
1. Additional activity epidemiological data and analysis
2. Relevant reporting from the Qualitative section/focus groups
3. An update on relevant policy and evidence
Policy and Evidence Update
Since June 2013
• Following the Prime Minister’s Challenge on Dementia, NHS England is investing £90
million in diagnosing two thirds of people with dementia by March 2015. As part of this,
NHS England will work with local areas where it takes up to 25 weeks to carry out
diagnostic assessments as compared to others where the wait is six weeks on average
• From April 2014, people diagnosed with dementia and their carers will also be able to
sign up to a new service on the NHS Choices website to get help and advice in the early
stages of their condition
• The Government has published an online Dementia Map showing regional and local
information on dementia, based on a range of data including diagnosis rates and referral
rates for further investigation (3).
Activity and Epidemiological Data
This section of the report sets out the numbers of referrals (i.e. commissioned activity) for
Bradford and Airedale and each of the Clinical Commissioning Groups, with the rates of
referral per 1,000 population added in order to take into account the different population
sizes of the CCGs.
Figure 1 below illustrates the number of referrals to Memory Services across Bradford
District from 2005-‐6 to 2012-‐13. There are a number of caveats that should be considered
when reviewing these figures.
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• SystmOne, a centralised clinical system that provides healthcare professionals with
electronic patient records, was rolled out across the GP practices over a number of
years and this is reflected in the data captured. As such, the lower numbers of
referrals seen in the early years may not fully reflect the numbers of referrals across
the district as not all practices were using SystmOne at that time
• There is likely to be some coding variation, for example in data on ethnicity,
although this has greatly improved over time
• Given these, It is felt that a consistent and robust pattern has been in place since
2008-‐9
A clear sustained year on year rise in referrals from 2005 to the present is shown. There was
a notably larger year on year rise between 2010-‐11 and 2011-‐12 although this was not
sustained with a more modest rise observed between 2011-‐12 and 2012-‐13. The trend
upwards suggests a need to build in rising capacity to service models, particularly given the
twin issues of ageing population and drive to identify a greater proportion of existing cases.
Figure 1 Referrals to Memory Services, Bradford and Airedale 2005-‐2013
Source: SystmOne
Bradford District -‐ Referrals to Memory Services 2005 -‐ 2013
0
100
200
300
400
500
600
700
800
900
2005-‐2006 2006-‐2007 2007-‐2008 2008-‐2009 2009-‐2010 2010-‐2011 2011-‐2012 2012-‐2013
Year
Num
ber
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Clinical Commissioning Groups CCG referrals are presented here as both numbers and rates. Numbers provide a picture of
actual commissioned activity and proportion of prevalent cases that have been diagnosed,
rates per 1,000 population present this adjusted to take account of the size of the CCG
populations.
Note -‐ MATS data are not currently available for Craven so what is presented here is for
AWCCG only
Table 1 and Figure 2 below show numbers of referrals to MATS services, by CCG, for the
period 2005-‐13. Clearly activity is greatest in BDCCG, this being expected due to its larger
population size in comparison with AWCCG and BCCCG. The trajectory is clearly steeper for
BDCCG indicating a greater rise over time than AWCCG and BDCCG who both show similar
patterns, rising slowly and appearing to level off in 2012-‐13 although whether this is
sustained is yet to be confirmed.
Table 1 Referrals to Memory Services, Numbers, by CCG, 2005-‐13
Source: SystmOne
AWCCG BDCCG BCCCG
2005-2006 5 18 <5
2006-2007 9 41 6
2007-2008 13 81 8
2008-2009 27 140 30
2009-2010 38 194 35
2010-2011 47 330 24
2011-2012 106 493 83
2012-2013 104 592 95
Grand Total 349 1889 284
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Figure 2 Referrals to Memory Services, Numbers, by CCG, 2005-‐13
Source: SystmOne
Table 2 and Figure 3 below show numbers of referrals to MATS services, by CCG, for the
period 2005-‐13. It is clear to see how the process of converting the numbers to rates has
brought the trajectories closer together by removing the impact of differing population
sizes. Nonetheless, BDCCG retains a steeper trajectory than the other CCGs, suggesting that
there is a true effect of BDCCG expanding its referrals at a greater rate than AWCCG and
BCCCG.
Table 2 Referrals to Memory Services, Rates/1,000 pop., by CCG, 2005-‐13
Source: SystmOne
0
100
200
300
400
500
600
700
2005-2006 2006-2007 2007-2008 2008-2009 2009-2010 2010-2011 2011-2012 2012-2013
Num
ber
Year
Referrals to Memory Services, Numbers, by CCG, 2005-2013
AWCCG
BDCCG
BCCCG
AWCCG BDCCG BCCCG
2005-2006 0.0 0.1 0.0
2006-2007 0.1 0.1 0.1
2007-2008 0.1 0.2 0.1
2008-2009 0.3 0.4 0.3
2009-2010 0.4 0.6 0.3
2010-2011 0.5 1.0 0.2
2011-2012 1.1 1.5 0.8
2012-2013 1.0 1.8 0.9
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Figure 3 Referrals to Memory Services, Rates/1,000 pop., by CCG, 2005-‐13
Source: SystmOne It is important to be aware that two current initiatives, the Dementia Direct Enhanced
Services (DES) payment framework in Primary Care and the Dementia Commissioning for
Quality and Innovation (CQUIN) payment framework in Secondary Care and are both
beginning to provide increased numbers of referrals to MATS from secondary care and
primary care respectively. These are addressed in Section 6a-‐ Primary Care and Section 6c –
Secondary Care respectively
Ethnicity
The SystmOne data did not allow for a comprehensive breakdown of referrals by ethnicity.
For example, it was not possible to quantify referrals from the Central and Eastern European
Community who are anecdotally reported to be rising in number, reflecting general changes
in demography across the District. Work carried out as part of the qualitative analysis (see
Section 8 – Qualitative Study) indicated that community based activity in the 3rd sector is
structured around five generalized ethnic groups; White; South Asian; Black; Italian and Irish.
It is important that data collection and analyses evolve to reflect this.
Figure 4 below provides an indication of how the overall rise in referrals to MATS services
across the District has been represented by three ethnic categories; White; Asian or Asian
British and Other/unclassified. The rise in the white community is reflected in the Other/Not
known group, however the rise in South Asian referrals seen in 2011/12 is not continued
into 2012-‐13 thus far.
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
2.0
2005-2006 2006-2007 2007-2008 2008-2009 2009-2010 2010-2011 2011-2012 2012-2013
Rat
e pe
r 1,
000
Year
Referrals to Memory Services, rates per 1000, by CCG, 2005-2013
AWCCG
BDCCG
BCCCG
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Figure 4 MATS referrals by Ethnicity, Bradford & Airedale 2010-‐2013
Source: SystmOne
Given the perceived relative lack of growth in referrals from the South Asian community
from 2011-‐13, the proportion of referrals from this community is set out in table 3 and
figure 5 below. It can be seen that, with the exception of 2010-‐11 where a single sharp dip is
noted, there is a broad maintenance of a percentage between 10 and 12% across the time
period. This is lower than the South Asian proportion of the general population (~20%).
Table 3 MATS referrals by Ethnicity, Bradford & Airedale 2010-‐2013
Source: SystmOne
Ethnic Group 2005-2006
2006-2007
2007-2008
2008-2009
2009-2010
2010-2011
2011-2012
2012-2013 Total
White 22 41 80 141 189 312 479 557 1821
Asian or Asian British <5 5 11 24 32 21 79 83 258
Other / Not known <5 10 11 32 46 68 124 151 443
Total 26 56 102 197 267 401 682 791 2522
% Asian or Asian British 11.54% 8.93% 10.78% 12.18% 11.99% 5.24% 11.58% 10.49% 10.23%
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Figure 5 Proportion of MATS referrals from South Asian Community,
Bradford District 2005-‐13
Source: SystmOne What does this mean for Bradford and Airedale?
There has clearly been a stready rise in referrals to MATS services from all three CCGs over
recent years. The majority of rising activity has been in BDCCG, reflecting both its size and an
indication that case finding has risen more rapidly in BDCCG than in AWCCG and BCCCG.
There is some indication of a slowing or plateauing of the rate of rise in referrals, and this is
to an extent supported by the findings of the CFAS II study (4), however this must be taken in
the context that the demographic projections remain that numbers of older people are
expected to continue rising (see Section 2, Epidemiology). An interesting consideration is
that there may have been an element of “mop up” in Primary Care where GP practices are
identifying large numbers in one year with the effect that much smaller numbers remain to
be diagnosed the following year. This is theoretical currently but plausible as it stands and
may be measurable and could have contributed
There is clearly a need to maintain and develop adequate provision for a prospective
continuing rise in number of people with dementia – the 3:2 ratio of diagnosed to
undiagnosed cases is significant here. There are two important dynamics underpinning this
process; an ageing population and better case finding in the present population. If we add in
to this the potential additional diagnoses from secondary care CQUINS and the Primary Care
DES, this forms a complex system that needs to be carefully monitored to ensure that
capacity reflects demand and availability of treatment and support.
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
2005-2006 2006-2007 2007-2008 2008-2009 2009-2010 2010-2011 2011-2012 2012-2013
Year
% A
sian
or A
sian
Brit
ish
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Figures show that rates of access to MATS services vary between CCGs (see Section 2 –
Epidemiology). It is important that all population groups are aware of and can access the
services. For example, the South Asian community are poorly represented (under the
assumption that ethnic make up of referrals should be expected to reflect that of the
general population). There are likely to be other factors influencing inequity of access, e.g.
deprivation (5), fear of diagnosis (6); practical difficulties in attending (7); complexity of the
system (8); lack of awareness among GPs (7).
There is a need to be mindful of the findings from the qualitative work relating to MATS, as
set out in Section 7, the key points being:
• The primary care environment is seen as less intimidating than hospital settings
• Some South Asian people do not like being seen attending mental health services or
follow up appointments for fear of stigmatisation
• Cultural attitudes to elders may be important in generating referrals
• MATS services should be identified as “memory” services with references to mental
illness avoided.
• There is a need for services close to home as travel can be difficult and costly
• MATS services should integrate with post-‐diagnosis support, for example hosting or
signposting to Wellbeing Cafes.
Considering all elements of this report, there are a number of themes and threads
suggesting that an integrated, community and primary care focused model of MATS services
would best serve the identified needs of the local population. Nonetheless, if this were to be
successful, it would need to be underpinned consistently by a clear, common pathway
across all elements of service in the District.
Recommendations
1. An integrated, community and primary care focused model of MATS services is likely to
best serve the identified needs of the local population
2. A local Steering Group should be established with a specific remit to develop and
implement a case-‐finding action plan to increase diagnosis among the ~2,000
undiagnosed cases already living in the district
3. The data contained in this report should be used to inform capacity:demand modelling
as new services develop
4. Services should be carefully advertised and described to patients and carers in order to
minimise fear and stigma
5. Services should be culturally appropriate and staff culturally competent
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6. Services should be underpinned by a district-‐wide common pathway
7. Data collection and analysis processes should be developed to provide robust detailed
data on the ethnicity of patients accessing MATS services
8. Further analysis of factors underpinning referral patterns in the South Asian community
should be undertaken to explain a perceived underrepresentation in referrals
References
1. Memory assessment service for the early identification and care of people with
dementia. National Institute for Health and Clinical Excellence 2007
2. Rhodes V. Review of Memory Assessment and Treatment Services and Acute Care
Home Liaison. Bradford and Airedale Clinical Commissioning Groups 2013
3. http://dementiachallenge.dh.gov.uk/map/ -‐ accessed 9th May 2014
4. Matthews FE, Arthur A, Purandare N, Bond J, Voshaar RCO, Rodway C, et al. A two-‐
decade comparison of prevalence of dementia in individuals aged 65 years and older
from three geographical areas of England: results of the Cognitive Function and
Ageing Study I and II. The Lancet. 2013 Oct;382(9902).
5. Larson EB, Yaffe K, Langa KM. New Insights into the Dementia Epidemic. N Engl J
Med. 2013 Nov 27.
6. All Party Parliamentary Group on Dementia. Unlocking diagnosis. The key to
improving the lives of people with dementia . House of Commons 2012
7. http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=260 -‐
accessed 2/6/2014
8. Haralambous B, Dow B, Tinney J, Lin X, Blackberry I, Rayner V, et al. Help seeking in
older Asian people with dementia in Melbourne: using the Cultural Exchange Model
to explore barriers and enablers. J Cross Cult Gerontol. 2014 Mar;29(1):69–86.