Thursday 3 June 2010


Times are changing. Allegedly. Although maybe not changing an awful lot, since our PCT 'fessed up today that the money the SHA has given them for the implementation of the National Dementia Strategy, not being ring fenced, has been swallowed up by other stuff and spent on other things. So it goes.

Cash that could have been used to improve dementia care therefore's evaporated and the acute Trust down the road grumbles along, despite the national picture reported by the Alzheimer's Society showing that, well, it's all a bit shabby.

Is there any hope, then? Locally, the acute Trust is working with us and is keen to improve. There's a lot of work to be done, though. For example, the DoH have accepted Prof Banerjee's report and recommendations around antipsychotic prescribing in dementia care. 180 000 patients with dementia on such drugs with only 36 000 getting benefit rightly raises concern that prescribing practice needs to be more robust. How're things to improve? Exceptionally and very hearteningly, there's no requirement for more committees and no desire for more management. The report requires that Medical Directors and existing governance structures deliver on this. Deliver on what? Just one bit of one recommendation is that the Trust has to ensure good practice in initiating medication. And ensure good practice if it's maintained (e.g. a patient comes in on it and the hospital ward continues to administer it to them). And ensure good practice in discontinuing medication. All sensible stuff.

What's intrigues me more is that in addition to the clinical quality improving, there Trust has to ensure this is done. So just bashing out some protocols or care pathways or policies or naming a couple Dementia Champions or Medicines Management Champions or Lead Practitioners or having a standard operating procedure or drafting guidance ain't enough. They need to ensure that the system works. First the clinical care has to improve, then evidence of this meaningful implementation needs to be generated. Without more managers or committees or nonsense.

Having met with PCT and LA and colleagues today, I am hopeful. But the acute Trust having to do this, with no new cash 'cause the PCT snaffled it . . . somehow this seems less than ideal.


Nikita said...

Hallo there!,

As a nurse happily and proudly working in social care, I thought I would respond to this post.

I am not suprised that the funds supposedly made available to enable the National Dementia Strategy have been swallowed up by SHA's to fund God knows whatever! I am perhaps naive, but if these funds were provided for dementia care, I do not understand why ring-fencing is neccesary as they were surely provided for the identified purpose. But old folk with dementia are of little importance to SHA's. But that is by-the-by.

I have re-read Prof. Banarjee's report and although I admire his good intentions - I do think that perhaps he has not had any experience of social care. I will quote:

"We will solve this problem by services working together, and there is a need for extra capacity to enable a programmme of in-reach work to all care home with people with dementia resident and to GPs in the community. We can build on our existing nationwide network of specialist commmunity older people's mental health services to deliver this."

This, unfortunately is idealism. Our experience would suggest that most GPs don't give a fig. They appear to regard requests for visits as time wasting and treat the staff (and indeed the residents needs) with disdain. We do have a very healthy relationship with our local psychogeriatrician.

A very few of our residents receive antipsychotic drugs and those that do surely need them. Life is not a bowl of cherries for some residents and their waking life is an experience of utter torment and distress. There is also the consideration of the needs of fellow residents who have to co-exist with these unfortunate souls. Our home readily accepts those who other homes can't 'deal' with.

Our residents are allowed to be themselves. They do not have to sit in a chair all day to make the home look 'tidy.' But at the same time we consider their needs. I must state that we feel quality of life supercedes quantity on all occasions.

If we feel a resident is over-drugged we will say so and it is amazing how a reduction in drugs will reveal a confused but relatively happy person, but at the same time if a resident is existing in a state of sheer hell we will request medication to alleviate this.

Dementia is not a goal in life.

pj said...

In our local area it must be that at least 90% of admissions for behavioural disturbance or psychiatric deterioration in patients with dementia are dealt with by the general hospital. Anti-psychotics are started because they are simply not resourced, designed, staffed, or trained to deal with behavioural disturbance non-pharmacologically (any new and idealistic doctor will learn within 3 months to just give in and prescribe) - whether they get discharged on these medications without further review is something of a lottery dependent on the GP and whether the junior doctor discharging even thinks about whether the risks outweigh the benefits. At no point will an experienced or senior clinician be involved in these decisions.

Alzgirl said...

Outrageous PCT.
Outrageous SHA (cannot or will not 'fine' PCT and give proceeds to Acute Trust).
Outrageous some GP's, as per 'Nikita', and outrageous situation in General Hospitals,as per 'pj'.
Not just for 'old folk' either.
What care can I expect as my MCI develops into dementia?
Bang Bang Bang - my head > brick wall! Add head injury now to speed it up!

The Shrink said...

Nikita, thank you for your very coherent and detailed comment! Your perspective, from your informed experiences, certainly resonates very much with how things are in my corner too. Ho hum.

PJ, sadly that's the norm, but hopefully objective 8 of the National Dementia Strategy will change that . . .

Alzgirl, indeed. Much badness.