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Improving dementia care

Country: 
United Kingdom
Partner Institute: 
London School of Economics and Political Science
Survey no: 
(14) 2009
Author(s): 
Adam Oliver
Health Policy Issues: 
Long term care, Quality Improvement, Responsiveness
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no yes no yes no no

Abstract

In February 2009, the Government released a National Dementia Strategy, which has the core aim of improving the welfare of dementia patients and those who care for them. This follows from the perception that care for dementia patients has been overlooked somewhat in the past. The government has outlined a governance, implementation and assessment strategy, and has strongly emphasised the need to involve local partners in order to improve care in this domain.

Purpose of health policy or idea

As in most countries, dementia clearly represents a huge challenge in the UK. The Government has stated that there are currently 700,000 people suffering from dementia in the UK (out of a total population of about 60 million), with dementia estimated to cost about £17 billion per year. With the ageing of the population, the Government estimates that the number of sufferers will increase to 1.4 million people thirty years from now, with an associated cost outlay of £50 billion per year. 

Apparently, only about one-third of dementia sufferers receive a formal diagnosis or have contact with a specialist. The Government has highlighted this as a major concern, in relation to the welfare of both the person with the illness and those with whom they live, and has also stated that greater investment in prevention, early intervention and community-based resources would pay for themselves, by them reducing the need for people to be admitted to expensive, long-term institutional care. 

The Government, as part of the new National Dementia Strategy (the first ever such strategy in this area), has highlighted a number of 'priority objectives', which are meant to address the concerns outlined above. Specifically, these objectives include: Good quality early diagnosis and intervention; Improved community support services; Improved quality of care for dementia sufferers in general hospitals; Improved experiences of those with dementia who are living in care homes; Improved information on dementia; A joint health and social care commissioning strategy for dementia.

The Government has stated that it is not going to prescribe which services should be planned, commissioned and delivered. Rather, it is placing a heavy emphasis on involving regional and local bodies to 'buy in' to the strategy, and is thus placing a focus upon the need for involvement at the local level. Indeed, the Government has stated explicitly that "for change to be effective and sustainable it has to be locally designed and owned". Consequently, the Government has recognised that the pace of implementation is likely to vary a lot depending on local circumstances. 

The emphasis on the local level is instructive, as within health policy, this may be a direction in which both main political parties (i.e. the Labour Party, currently in government, and the Conservative Party, who seem likely to be elected to government in May 2010) are likely to travel to an increasing extent over the coming years. One could be cynical by saying that devolvement to the local level may be intended to 'pass the buck' onto others (i.e. it places the burden responsibility and health policy 'success' onto those outside of central government). However, a more plausible explanation is the growing 'ethos' that the improved delivery of services (in general) cannot be effectively realised without the close involvement of local 'actors'. It will be interesting to observe whether the seemingly higher emphasis on local governance continues to increase in the years ahead (I predict that it will do, as it is consistent with the ethos of 'personal responsibility', which now dominates the policy discourse).  

It is important to note, however, that the central government will continue to oversee the strategy. The Department of Health has established a Programme Board for implementation, with is supported by an Implementation Group. Moreover, the Department of Health policy leads within the Implementation Group will co-ordinate actions within the Department and also across other government departments so as to ensure continued engagement with the strategy and to try to limit duplication of efforts. A 'Core National Team' within the Implementation Group will also lead specific projects with national bodies, such as the Royal Colleges, work with regional heads of social care and local partnerships on mutually agreed initiatives, and support cross-regional work and policy learning.   

Main points

Main objectives

The main objectives are outlined above, but to reiterate, they include: To provide good quality early diagnosis and intervention; To improve community support services; Improve quality of care for dementia sufferers in general hospitals; Improve experiences of those with dementia who are living in care homes; Improve information on dementia; To establish a joint health and social care commissioning strategy for dementia.

Type of incentives

A number of 'demonstrator' sites will provide new information on such measures as ease of access to care, support and advice following dementia diagnosis. Various data on the quality of dementia services will be used to form a national 'baseline' measure, which is intended to work as a benchmark for the regions, and willl also help to ensure that support is targeted at those regions where services are currently the least developed.

It is difficult to comment further at this point on what form the incentives are likely to take, because different initiatives will presumably be developed across the different local level areas. Empowering local leadership is, however, clearly a key aim, and the government has proposed a host of ways by which local level 'buy in' may be achieved. These include soliciting local specialist expertise to build local conditions for change, enabling clinicians to engage as leaders in change initiatives, stimulating interest among local leaders in the potential for mutual approaches between the department of health and the local level, acting as a catalyst for local stakeholders to determine their own engagement and strategies, advising local leadership on evaluation design and programme measures, and brokering models of good practice, among other things.

Groups affected

Dementia patients and carers, National and local government, Primary care trusts

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Characteristics of this policy

Degree of Innovation traditional innovative innovative
Degree of Controversy consensual rather consensual highly controversial
Structural or Systemic Impact marginal neutral fundamental
Public Visibility very low neutral very high
Transferability strongly system-dependent rather system-neutral system-neutral

The policy is innovative, and I don't perceive huge disagreements associated with it. I am not yet sure what structural impact it will have (and nor is anyone else). I don't sense that general public visibility of this strategy is high, but I also don't see why the strategy necessarily has to be specific to the UK.

Political and economic background

The policy initiative has not been caused by a change of government or a change in the law or anything of that nature. It is simply part of the current Government's ongoing drive to improve health and social care, and reflects a growing recognition that mental health care has perhaps not received as much attention as it ought to have done over the past several decades (and before). Dementia also obviously fits in with concerns vis-a-vis the ageing of the population. This all said, the Strategy is mainly at this point at the 'rhetorical' stage. It has yet to achieve anything in concrete delivery terms, and only time will tell if it eventually does.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no yes no yes no no

Origins of health policy idea

This has all been detailed above. In short, it is a new strategy to improve dementia care, which was informed by a public consultation exercise and which places a heavy emphasis on local partner involvement in planning and delivery.

The Government has allocated £60 million for 2009/10 and £90 million for 2010/11 to fund the strategy, which thus represents less than 0.001% of the NHS budget. Most of this funding will be directed towards evaluation and collecting evidence so as to try to gain an understanding of which initiatives might be worth developing at the national level. Funding beyond this initial two year period will be determined by the evidence of effect.

Initiators of idea/main actors

  • Government
  • Civil Society

Approach of idea

The approach of the idea is described as:
new: It is a new strategy for dementia

Innovation or pilot project

Local level - The Government has set up some demonstration sites, and hopes that these will be able to produce some evaluations and results over the next two years.

Stakeholder positions

I am not really aware of any strong opposition to the new strategy. Presumably, the mental health community are in favour of it, because it highlights a need to do something positive in the area of dementia. The Alzheimer's society, as special interest group, is in favour of the strategy, but has cautioned that a positive effect will require real political commitment from the Government (Help the Aged has been similarly positive). As noted above, the Government formulated the strategy following a public consultation exercise, so they would have taken into account the expertise, advice and opinions offered forth by all relevant stakeholder groups. The need to very much involve local governance structures was clear following the consultation exercise; local involvement is presumably something that most stakeholders - operating in large part locally themselves - would desire. In sum, I don't detect and strong opposition to the strategy. 

Actors and positions

Description of actors and their positions
Government
Central governmentvery supportivevery supportive strongly opposed
Local governmentvery supportivesupportive strongly opposed
Civil Society
Alzheimer's societyvery supportivesupportive strongly opposed

Influences in policy making and legislation

Not applicable. The strategy is part of the Government's health and social care policy. The strategy has now been implemented.

Legislative outcome

n/a

Actors and influence

Description of actors and their influence

Government
Central governmentvery strongvery strong none
Local governmentvery strongvery strong none
Civil Society
Alzheimer's societyvery strongneutral none
Central governmentAlzheimer's societyLocal government

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

Much of this has also been detailed above. Department of Health regional teams have been charged with monitoring the progress of implementation of the strategy, and with reporting on this progress at both the regional and national levels. Primary Care Trusts, which choose areas in health care to target for improvement, have also been encouraged to identify dementia services as one such area. Within a 'Joint Strategic Needs Assessment' process which is undertaken together with the local authorities, PCTs will be encouraged to develop and implement high quality dementia care strategies that serve to meet local needs. Special Health Authorites (SHAs) hold PCTs to account for health services delivery generally, and thus the performance of PCTs vis-a-vis dementia care will be monitored by SHAs as part of this process - the SHAs are in turn accountable to the Department of Health. Moreover, the Care Quality Commission (CQC) assesses the performance of local authorities, and makes judgements appertaining to social care outcomes, of which the dementia strategy will form an important part.

In short, a whole range of national and local government and health care bodies are involved in implementing the plan, and a sophisticated system of governance and monitoring has been established.

Monitoring and evaluation

Again, this has already been explained above. But it might be worth noting that the Department of Health is working towards developing a 'Dementia Metrics Framework', with which improvements in dementia care will be measured. Measures included in the Framework will include increases in diagnosis, increases in the number of dementia patients receiving appropriate care, participation in dementia care clinical audit by general hospitals, and improvements in quality scores in dementia care homes.  

Review mechanisms

Review has not been undertaken yet. It is expected that performance assessment against the above stated measures will be undertaken over the next two years.

Dimensions of evaluation

Structure, Process, Outcome

Results of evaluation

The evaluation has not yet been undertaken.

Expected outcome

It is very difficult for me to reach a personal conclusion, as I am not an expert in dementia care. However, the devolvement of much responsibility to the local level seems quite sensible to me, as it seems clear (and probably obvious) that local involvement and 'buy in' is crucial to improve most health services, and particularly those areas of care that rely on a co-ordinated effort between health and social care oganisations, and other stakeholder groups. I also think that the Governments strategy to implement a 'methodical process', in trying to find out first what seems to work across the different regions with a view to using existing initiatives in a national strategy, is a good idea. I agree with the Alzhiemer's Society that real improvement is likely to require political commitment at national and regional government levels. But I see no obvious flaws in the policy. It will be interesting to see how the strategy plays out, particularly, perhaps, as there is likely to be a change in the governing party in 2010, and particularly in light of the fact that NHS resources are almost certain to become increasingly constrained. Which might beg the question, will mental health services resources be among those that are constrained the most? 

Impact of this policy

Quality of Health Care Services marginal neutral fundamental
Level of Equity system less equitable neutral system more equitable
Cost Efficiency very low neutral very high

I have no idea on how to rate the policy yet. If it works, it will improve quality of care for dementia sufferers, which will improve equity, if one is trying to narrow the gap between the quality of care and health outcomes between those with dementia and those without. If it is dementia sufferers in lower socioeconomic classes who currently suffer the most, the strategy also has the potential to narrow inequalities across social classes, the principle domain of equity concern in UK health policy. I cannot comment on the efficiency of the strategy, because (a) we do not yet know the outcomes, and (b) we do not yet know the cost.

References

Sources of Information

Department of Health. Living well with dementia: a national dementia strategy implementaion strategy. Department of Health, London: 2009.

Department of Health. Living well with dementia: a national dementia strategy impact assessment. Department of Health, London: 2009.

www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_097629

http://alzheimers.org.uk/ndstrategies

 

Author/s and/or contributors to this survey

Adam Oliver

Suggested citation for this online article

Oliver, Adam. "Improving dementia care". Health Policy Monitor, October 2009. Available at http://www.hpm.org/survey/uk/a14/4