National Audit Office - Improving services and support for people with dementia

Introduction
Whilst this report focuses on dementia services in England, there are still some relevancies for Scotland. The report is largely critical of existing policy development and service provision. The evidence utilised by the report includes a survey of GP’s, web forum/focus groups with service users and unpaid carers and a whole system case study of provision for people with dementia.

Part one – Dementia presents a significant and urgent health challenge

• Sets out the new baseline information available on dementia. The Dementia UK report, analysis of wider social care costs and the results of the Departments first ever mapping exercise of older people’s mental health services.
• It was not until 2005 that the Department of Health developed policy specifically directed towards older people’s mental health issues. Dementia and older people’s mental health in general, have not benefited sufficiently from advances made as a result of the National Service Frameworks for older people and mental health. Dementia was also not specifically considered in the National Service Framework on Long Term Conditions, which focuses mainly on other neurological conditions.
• Acknowledges that most dementia care takes place in the community and most costs fall to families. It also sets out the key public bodies/types of service concerned in the delivery of care for people with dementia.
• Discusses therapies and treatments that can help with the symptoms of dementia.

Part two – Services in England could do better on early diagnosis and intervention

• Acknowledges that evidence shows early diagnosis and intervention improve outcomes for services users and unpaid carers. However, the UK’s performance on diagnosis compares poorly with other countries. States that awareness and attitudes among people with dementia and family carers as a key barrier to diagnosis. Fear of the disease coupled with the failure to distinguish between symptoms of dementia and normal signs of ageing are the main obstacles.
• GP attitudes and skills can be a gateway or a barrier to diagnosis – there are no official figures on GP’s with special interest in dementia, the number is thought to be very small. It is not uncommon for GPs to dismiss dementia symptoms as normal effects of ageing. In a NAO study, GP’s had a 47% success rate in answering questions on dementia.
• Specialist services are often best placed to diagnose but these are patchy and roles are unclear – there is no consensus on which speciality within medicine should take the lead in diagnosis and treatment of dementia or how such treatment should be delivered. Less that two thirds of GP’s surveyed by National Audit Office agreed they had access to specialist advice locally to help with diagnosis and managing dementia. Three quarters of GPs surveyed said they were unaware of any protocol or guidance for diagnosis and management of dementia in their area, despite local health communities should have had one in place since 2004.
• A significant proportion of people with dementia may have their first contact with health care services when they suffer an acute health episode and present at A&E. Detection of cognitive impairment in medical units after admission, including those specifically for older patients, is very patchy and formal diagnosis of dementia is not seen as a priority in these wards.

Part three – Management of community care following diagnosis is disjointed and often ineffective

• Community mental health teams (CMHT) are intended to serve as the central contact for people with dementia and work with other parties on their behalf. However, many do not come into contact with the majority of people in the community with dementia. CMHT’s have an average of 275 people with dementia under their care, given their coverage they are expected to find around 1,000 people with dementia in the community. CMHT’s were also found not to be providing the full range of services that they are intended to.

Part four - There are opportunities to improve the quality and cost effectiveness of the system’s response to dementia

• Joint working between health and social care is crucial to improving services, however, the lack of joint funding is a barrier to this and initiatives to bring together health and social care locally have had limited success.
• As a result of low priority nationally, as well as poor quality information on local needs, health and social care economies in England have tended not to undertake any effective long-term planning. However, work by the NAO has shown that a relatively quick information gathering exercise can provide data for health and social care commissioners to use in strategic planning.
• Early, effective intervention could save money and help families. Early diagnosis and support gives people the opportunity to make choices and plan for the future when they are relatively well. Interventions to reduce unpaid carer stress could delay unplanned entry to residential/nursing home care for the person they care for. Case management by mental health teams could provide a framework for coordinated dementia care, preventing hospital admission or enhancing hospital care and avoiding unnecessarily long stays.
• Greater understanding of dementia and its care by public and professionals is a priority that can be addressed through better training for care staff and addressing the stigma.

Appendix two – International comparisons
Provides some summarised comparisons between the UK and other countries:

• There is no international consensus on which speciality within medicine should take the lead in diagnosis and treatment.
• All countries are still wrestling with the challenge of how to finance long term care services over the coming decades.
• Differences between England and other parts of the UK in per capita expenditure, per capita provision and unit cost for residential and nursing homes, home care and day care are quite marked. (No breakdown of UK figures provided)

The full report is available on the National Audit Office website
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