The talk I will give on May 13th 2016 for the Annual Conference of the Community Hospitals Association. This event will be held in Bristol.

1. Community Hospitals Association
Challenging Times
Improving the experience of dementia through
community hosptials
Friday 13 May 2016 : 1.50 pm
Bristol Marriott Royal Hotel, College Green Bristol
Dr Shibley Rahman
MA PhD MRCP(UK) MBA LLM
Fellow of the England Centre
for Practice Development
o

2. About 800,000 living in the UK with dementia.
Dementia is an umbrella term, covering more
than 100 conditions.
Progressive – no longlasting symptomatic
treatment as yet. Policy aimed @ living better.

4. • Goals should be SMART – specific,
measurable, achievable, realistic and time-
oriented.

6. Impact of community services (King’s
Fund 2014)
The main steps identified are:
• reduce complexity of services
• wrap services around primary care
• build multidisciplinary teams for people with complex needs,
including social care, mental health and other services
• support these teams with specialist medical input and redesigned
approaches to consultant services – particularly for older people and
those with chronic conditions
• create services that offer an alternative to hospital stay
• build an infrastructure to support the model based on these
components including much better ways to measure and pay for
services
• develop the capability to harness the power of the wider community.

8. • Landscape of some services
• English dementia strategy
• Difference between community and centralised large
hospitals
• Learning from the acute hospital experience
• Dementia friendly environments including ward
settings
• Specialist nurses and palliative care
• Carers
• Antipsychotics
• Rights, enablement and rehabilitation

15. Small et al (2009) Post-acute rehabilitation care for older people
in community hospitals – Philosophies of care and patients’ and
caregivers’ reported experiences: A qualitative study. Disability
and Rehabilitation, 31: 1862-1872.

17. Acute hospitals
• Individuals with dementia who are in hospital can
be greatly distressed by unfamiliar environments.
• This might be a combination of cognitive
difficulties and poor environments.
• Prolonged hospital stays can lead to exposure of
hazards including risk of falling or infections, for
example.

19. National Audit of Dementia
Skilling up the workforce
• The 2nd round report highlighted that
approximately 75% of hospitals now provide
dementia awareness training to nurses.
• Almost 50% are still failing provide demenrtia
awareness training as part of induction.
• This report finding suggests that further
improvement is needed to provide better, more
consistent staff training.

22. Harwood, 2012
• Forty per cent of acute general medical
admissions over the age of 70 have dementia.
• Cognitive impairment is evident in 60% of
patients on acute geriatric medical wards, and
in 55% of patients with hip fracture.
• Overall, 25% of hospital beds accommodate
someone with dementia

23. Harwood, 2012
“Family members and carers of people with
dementia are frequently dissatisfied with their
experience of hospital care, including staff not
recognising or understanding dementia, lack of
activity and social interaction, inadequate
involvement in decision making and perceived
lack of dignity and respect.”

24. Guardian (June 2014)

25. Guardian (June 2014)

26. Guardian (May 2014)

28. Delayed/inappropriate discharges (NHS
Confederation, 2010)
“Dementia is a predictor of a higher probability
of inappropriate or delayed discharge. The
opportunities of improvement through better
discharge are significant. Reviewing the process
and auditing readmissions associated with
dementia are an important part of ensuring high
performance in this area.”

29. Duchenko and Wood (2015) “Hippocampus”

30. Priorities of “dementia friendly hospitals” from
Dementia Action Alliance
• The environment in which care is given
• The knowledge, skills and attitudes of the
workforce
• The ability to identify and assess cognitive
impairment
• The ability to support people with dementia to
be discharged back home
• The use of a person centered care plan which
involves families and carers.

31. Wayfinding techniques
• Accent colours
• Artworks
• Identification of bays, beds and social spaces
• Signage – pictures and text

32. Orientation techniques
• Artworks that reflect the seasons
• Calendars
• Large face clocks
• Natural light
• Outside spaces
• Photographs of local scenes
• Signs denoting ward and hospital name
• Views of nature
• Visible staff

33. Enhancing health environments (King’s Fund)

34. Mitchell (2016) “Doll therapy”

37. Rahman (2014)

38. Rahman and Dening (2016)
Caring for a person with dementia affects the health
and wellbeing of family carers.
In the UK, government policy has increasingly
highlighted the need to improve the lives of these
carers and the current approach is for them to have
access to a range of psychosocial and practical
support.
However, support available to carers is too often
fragmented and inadequate.

39. It is impossible to deliver person-centred care
unless you treat staff in a person-centred way.

40. Rahman and Dening (2016)

41. Rahman and Dening (2016)

42. Carers Trust/RCN (2015) “Triangle of care”

44. Rahman and Dening (2016)
Palliative care is offered to improve quality of life,
and there is growing evidence that an early
palliative care approach benefits people with any
type of chronic life-limiting illness (Beernaert et al,
2015), including dementia.
It can improve their quality of life and that of their
families by preventing or relieving suffering through
early identification, assessment and treatment of
pain and other poblems (World Health Organization,
2011).

45. Oliver (2016)
“As many as 40% of hospital patients over 75 have
dementia. It travels with them, although they’re
generally admitted for other primary reasons. They’re
more likely to die in hospital and to experience
decompensation, depersonalisation, and harms.”

46. Oliver (2016)
“We soon forget how far we’ve come and the
importance of celebrating success, no matter who
helped to start or tend the fire.”

48. Principle 1:
Staff who are skilled and have time to care
Principle 2:
Partnership working with carers
Principle 3:
Assessment and early identification of dementia
Principle 4:
Care plans which are person centred
and individual
Principle 5:
Environments that are dementia friendly

50. “Dementia champions”

53. Examples
Northern Devon Healthcare Trust (NDHT) has
joined national initiative John’s Campaign.
It has been launched in both its acute and
community hospitals, including Exeter Community
Hospital; Seaton Community Hospital; Sidmouth
Community Hospital; Exmouth Community
Hospital; Ottery St Mary Community Hospital;
Honiton Community Hospital; and Tiverton
Community Hospital.

58. Antipsychotics in the community
Health Services Journal (Oboh, 2014)
Every year 180,000 antipsychotic prescriptions are written for dementia
patients in England, causing an estimated 1,800 additional deaths and
1,620 cerebrovascular adverse events, according to the Banerjee report
in 2009.
GPs prescribe most of the antipsychotics in primary care via repeat
prescribing, although they are often initiated by prescribers outside
primary care.
GPs are reluctant to discontinue prescribing in spite of the associated
risks and evidence that many patients will have no worsening of
symptoms when discontinued.

59. • Undertake an audit and reduction exercise; and
• Identify local experts to provide clinical
support to GPs and champions to facilitate
collaborative working between primary, acute
and mental health teams.

60. Rights-based advocacy: the importance of the
European Convention on Human Rights

61. • Article 2 – the right to life (with virtually no
exceptions)
• Article 3 – prohibits inhuman or degrading
treatment or punishment (with no exceptions or
limitations)
• Article 5 – everyone has the right to liberty and
security of person (subject to lawful arrest or
detention, which can include people with mental
disorders)

62. • Article 6 – everyone has a right to a fair trial (including
a to defend himself or herself in person or through legal
assistance of his own choosing)
• Article 8 – the right to private and family life (subject
to certain restrictions that are “in accordance with the
law” and “necessary in a democratic society”)
• Article 14 – freedom from discrimination, including on
the grounds of disability (but only in respect to the
person’s rights under the Convention).

64. Rahman (2015) – work by Swaffer (2014)

67. World Health Organization
“Community based rehabilitation”
The aim of community-based rehabilitation
(CBR) is to help people with disabilities, by
establishing community-based programs for
social integration, equalization of opportunities,
and rehabilitation programs for the disabled.

68. Different types of persons using
Buurtzog
• Chronically ill and functionally disabled
clients
• Elderlyclientswithmultiplepathology
• Clients in a terminal phase
• Clientswithsymptomsofdementia
• Clients who are released from the hospital and
are not yet fully recovered

69. • Landscape of some services
• English dementia strategy
• Difference between community and centralised large
hospitals
• Learning from the acute hospital experience
• Dementia friendly environments including ward
settings
• Specialist nurses and palliative care
• Carers
• Antipsychotics
• Rights, enablement and rehabilitation