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Whole-pathway improvement involving collaboration between the primary, acute and community sectors

This is one of five examples from our report Making the case for quality improvement: lessons for NHS boards and leaders. Each example illustrates how quality improvement approaches are being used by teams and organisations in different parts of the NHS in England to improve care and value for money.

Dementia Golden Ticket: NHS High Weald Lewes Havens Clinical Commissioning Group

What was the problem?

Sussex has more people living with dementia than anywhere else in England (NHS Sussex 2013). Yet a local clinical review conducted prior to a project carried out by NHS High Weald Lewes Havens Clinical Commissioning Group found that their care experiences were often poor. Access to information and support was fragmented, primary care was frequently ill-equipped to manage slow-declining dementia and post-diagnostic support was limited. The aim of the project was to redesign the dementia care pathway to provide a more co-ordinated and responsive service in the community, while allowing secondary care mental health services to concentrate resources on more complex cases.

What did they do?

Over the course of six months, a core project team – working closely with partners across the health and social care system, including people with dementia and their carers – built up a detailed picture of how care was being delivered and what needed to happen to improve people’s care experience and quality of life. After securing buy-in from senior leaders in local primary care, community care, acute care, social care and voluntary sector organisations, a series of project groups, involving clinicians and people with dementia and their carers, was set up to design and develop the core aspects of a new care model. 

This new care model was then piloted in one GP practice in Buxted in Sussex in 2015 for three months. Through this model, the patient is referred by their GP to a multidisciplinary team, who then allocate an appropriate professional to carry out a comprehensive assessment in the patient’s home, rather than in a hospital memory clinic. The multidisciplinary team then meet to consider the person’s diagnosis, which is delivered in the patient’s home, and a ‘Golden Ticket’ is issued, aimed at providing the patient with a co-ordinated package of care in the community, built around their needs and preferences. A weekly GP clinic has been set up to co-ordinate rapid interventions for people with dementia seen to be at risk of deterioration, while peer support and signposting to other services are available through a memory café. Also, a new ‘dementia guide’ role has been created to support people and their carers through their entire care journey.

What impact has it had?

The results from the pilot in Buxted were encouraging. The new model had a positive impact on the emotional and physical wellbeing and quality of life of people with dementia and their carers. People involved in the project also reported that they felt more able to live independently and had better access to information and advice. A reduction in GP consultations and acute care attendances and admissions was also reported. However, given the small number of patients involved in the pilot, the full impact of the new model will only become apparent once its planned roll-out to other practices within the clinical commissioning group’s area is complete. Nonetheless, local system leaders have sufficient confidence in the model at this stage to earmark it for adoption across the whole of the Sussex and East Surrey Sustainability and Transformation Plan footprint. 

Other work from the project