Dementia

A Joint Strategic Needs Assessment – undertaken by place partners, including CW&C Council and the Cheshire and Merseyside Integrated Care Board (ICB) - will help inform current and future health, care and wellbeing needs of our local community to support local decision making. The information from the JSNA will guide a dementia care pathway and further action planning to ensure we are tackling inequalities, and wider determinants that impact on health and wellbeing.

Partners need to ensure that if a person is showing signs of dementia, that they and their carers feel supported to seek a diagnosis. It is also important that any diagnosis is made in a timely manner, and the person receives the right assessments and information. Ensuring the best possible experience of care and support post-diagnosis too.

Place partners also need to ensure that we have the right resources in place to support dementia carers, providing a seamless link with health and carers services to ensure carers are referred at the point of diagnosis.

Outcome:

A collaborative approach between organisations, utilising existing resources in a system that places those with dementia at the heart of the service.

What will we do:

Support Place partners to:

• Collaboratively produce an updated Dementia JSNA to inform our pathway and future action planning.
• Develop a single pathway which is deliverable boroughwide so that it is inclusive for all our residents, linking in with carers pathways where applicable.
• Design a pathway that supports an integrated approach that has step-by-step guidance for locally commissioned services, and providers to ensure sustainable delivery.
• Ensure the pathway focuses on timely responses to provide those living with dementia the support they need when it’s needed.
• Periodically assess and review the pathway to ensure it continues to meet the needs of our residents.

To build upon the work to date to tackle dementia diagnosis rates, and provision of support system partners need to review the action plans and ensure they are fit for purpose, they focus on a boroughwide approach and take on board the impact of COVID-19. The action plans need to focus on key elements of dementia including:

• Preventing well
• Diagnosing well
• Living well
• Supporting well
• Planning well

Outcomes:

A clear, concise, and realistic action plan that is developed by key partners and organisations and those living with dementia and their carers.

What we will do:

Support key stakeholders to co-produce a detailed dementia action plan for the whole borough that:

• Develops a person-centred approach that incorporates the views and feedback of those living with dementia and their carers.
• Reviews progress to date, evaluates best practice and evidence-base.
• Ensures a borough wide approach that tackles the health inequalities, and raises awareness of dementia – prevention, diagnosis, support, and how to become a dementia inclusive society.
• Maps current and future needs along the NHS England’s Well Pathway for Dementia (10).
• Reviews and develops training and education of health professionals and partners.
• Agrees realistic timescales and ensures robust sustainability of recommended actions.
• Considers the impact of COVID-19 on our ageing population and how it has affected those living with dementia and their carers.
• Takes into account other strategic and operational plans across the borough.

To support key partners to implement the action plan(s), and to monitor and review progress we need to create a group of key stakeholders to take on this accountability. The group will ensure that we are actively focusing on our outcomes, and that our work to tackle dementia will continue sustainably.

Outcome:

The strategy and action plan(s) focus on the key elements of prevention, raising awareness of dementia (for timely diagnosis, and our society’s perceptions), and for support and future planning.

What will we do:

Support system partners to:

• Review and redesign existing delivery and governance structures.
• Establish a group to develop. take ownership and drive forward the action plan, with agreed clear lines of accountability for delivery and monitoring.
• Assess and reflect on progress to date to ensure the group actions are up to date and in line with prevention services, and the needs of those with dementia and their carers.