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In April, the Department of Health launched its pilot programme to test new models of integrated care.

Sixteen sites were chosen for the programme of integrated care pilots - integration here referring to partnerships, systems and models as well as organisations - crossing boundaries of primary, community, secondary and social care.

The pilots will run for two years and will be evaluated over three years against a set of national and local measures. They will test a number of diverse models focusing on innovation, improving quality and patient satisfaction.

As an area with a higher than national average percentage of older people, a proven track record in multi-agency working (Queen Mothers Award in Intermediate Care 2001) and in the face of the new Dementia Strategy, it is unsurprising that NHS Bournemouth and Poole was given the opportunity to develop a pilot of new ways of working with demented patients.

Not only the PCT but multiple other agencies (local authorities/ mental health trust/ charitable organisations) are involved in this integrated care pilot for patients with memory loss and dementia. Working upon a GP locality group consisting of four practices, a multi-disciplinary team aims to deliver high quality care for these patients whilst integrating with current provision.

Early intervention services along with crisis and home services will face many challenges, not least working across the boundary of local authorities in the face of practice based commissioning. Aiming at three groups of patients (diagnosis in the mildly cognitive impairment / those who meet the criteria for NICE treatment of SDAT / patients with advanced problems requiring more intensive support or crisis support) the team will aim to overcome boundaries between older people’s health care and older people’s mental health care. To achieve this, teams of health and social care will not only be co-located but also have a single management system.

The scheme aspires to interventions of about 2 weeks (extendable to 6 weeks) available 7 a.m. to 10 p.m., 7 days a week. A team consisting of mental health nurses, medicines management technicians, social worker and specially trained home care assistants will have access to advice from consultant geriatricians and psychiatrists as needed and link to the generic care services once the intervention is over. A key aspect will be case finding. Presently there is evidence that only 40% of cases of dementia are accurately recorded.

Vital in the low level patients at first diagnosis is the role of a dementia advisor to explain and support through the diagnosis being made and to help in the development of crisis plans before crises arise. This will be supported by ideas such as dementia cafes / a floating support service and church support. Signposting to the service will also be available form other aspects of the community e.g. emergency services / pharmacies.

In order to keep things relevant to the needs of patients and carers a steering group with both groups represented will be developed.

We shall report back next year on our progress.

Matt Thomas
Consultant Physician
Poole Hospital NHS Foundation Trust

BGS Newsletter, July 2009
Issue 22 ISSN 1748-6343 22