Commissioning a memory assessment service for the early identification and care of people with dementia

Memory assessment services offer a responsive service to aid the early identification of dementia, and include a full range of assessment, diagnostic, therapeutic and rehabilitation services. Memory assessment services ensure an integrated approach to the care of people with dementia and the support of their carers, in partnership with local healthcare, social care and voluntary organisations^[1], and have been shown to significantly improve the quality of life of carers and people with dementia^[2].

Dementia refers to a syndrome characterised by a deterioration of cognitive functions that is usually progressive and eventually severe. There are many types of dementia, of which Alzheimer’s disease is the most prevalent accounting for over 50% cases^[3].

Dementia is one of the most pressing challenges facing health and social care in the UK. The direct costs of Alzheimer’s disease alone exceed the total costs of stroke, cancer and heart disease combined, and the overall economic burden has been estimated to be over £14 billion per year in the UK^[4].

Dementia affects one person in twenty over the age of 65 years,and one in five of those over the age of 80. It is estimated that the number of people with dementia in England will have risen from the current 574,000 to 793,000 by 2021, substantially increasing the already considerable financial and social burdens of this disorder^[5].

In current practice, the diagnosis of dementia is often delayed for several years after the initial onset of symptoms. Experts and the Department of Health agree that early diagnosis and intervention in dementia is cost-effective, yet there is a significant diagnosis gap, and only between a third and a half of people with dementia ever receive a formal diagnosis^[6]. The early recognition and detection of dementia enables people with dementia, their families and clinicians to plan more effectively for the future^[7] and can improve quality of life for both the person with dementia and their carer(s)^[8].

Primary care is often the point of first medical contact for people with suspected dementia and hence is the cornerstone of ensuring early detection and intervention, as well as effective ongoing management ^[9]. Early detection and intervention enables more timely access to treatments^[10] and ultimately reduces total care expenditure by delaying the need for long-term care and other costly outcomes^[8].

Benefits

The potential benefits of robustly commissioning an effective memory assessment service for the early identification and care of people with dementia include:

• providing a cost-effective way of significantly increasing the number of people seen for early diagnosis and intervention
• reducing total care expenditure by delaying the time to nursing home admissions and other costly outcomes^[8]
• breaking down the stigma of dementia and potential barriers to recognition/diagnosis, and reducing refused referrals
• improving the quality of life of people with dementia and their carers by promoting and maintaining the independence, including mobility, of people with dementia for as long as possible
• improving performance and patient-centred clinical care through implementing the recommendations outlined in NICE–SCIE clinical guideline CG42 on dementia
• reducing inequalities and improving access to appropriate treatment and support
• increasing patient choice, and improving partnership working, patient experience and engagement
• better value for money, through helping commissioners to manage their commissioning budgets more effectively – this may include opportunities for commissioners to undertake local service redesign to meet local requirements in novel ways.

Key clinical issues

Key clinical issues in providing an effective memory assessment service for the early identification and care of people with dementia are:

• accurately identifying and referring all people who present with signs and symptoms of possible early dementia
• ensuring that appropriate referral pathways are in place
• providing comprehensive assessment and diagnosis of dementia, including subtype diagnosis
• providing an integrated approach to care coordination and implementation across all agencies involved in the treatment and care of people with dementia and support of their carers
• providing a quality assured service.

National priorities

National priorities and initiatives relevant to commissioning a memory assessment service for the early identification and care of people with dementia include:

• Living well with dementia: a National Dementia Strategy
• ‘World class commissioning’.
• ‘The NHS in England: The operating framework for 2009/10'.
• ‘National service framework for mental health: modern standards and service models’.
• ‘National service framework for older people’.
• ‘Everybody’s business. Integrated mental health services for older adults: a service development guide’.
• ‘Commissioning framework for health and well-being’.
• National Audit Office report ‘Improving services and support for people with dementia’.
• ‘Delivering the 18 week patient pathway’.
• The ‘Single assessment process’.
• The ‘Care closer to home’ initiative outlined in chapter 6 of the white paper ‘Our health, our care, our say’.
• Considering the impact of patient choice.
• ‘A stronger local voice: a framework for creating a stronger local voice in the development of health and social care services’.
• Implementation of NICE clinical and public health guidelines. These are currently core standards, and performance against these standards will be assessed by the Care Quality Commission in line with ‘Standards for better health’.

Although many or all of these priorities may be relevant to the services nationally, your local service redesign may address only one or two of them.

References

1. National Institute for Health and Clinical Excellence (2006) Dementia: supporting people with dementia and their carers in health and social care. NICE–SCIE clinical guideline 42. London: National Institute for Health and Clinical Excellence.

2. Wanless D (2006) Securing good care for older people: taking a long-term view. Wanless Social Care Review. London: Kings Fund.

3. van der Flier WM, Scheltens P (2005) Epidemiology and risk factors of dementia. Journal of Neurology, Neurosurgery and Psychiatry 76 (suppl. 5): v2–v7.

4. Lowin A, McCrone P, Knapp MRJ (2001) Alzheimer’s disease in the UK. Comparative evidence on costs illness and volume of health services research funding. International Journal of Geriatric Psychiatry 16: 1143–8.

5. Kings College London and London School of Economics (2007) Dementia UK. A report to the Alzheimer’s society on the prevalence and economic costs of dementia in the UK. London: Alzheimer’s Society.

6. National Audit Office (2007) Improving services and support for people with dementia. London: The Stationery Office.

7. England E (2006) Improving the management of dementia. British Medical Journal 332: 681–2.

8. Relkin N (2000) Screening and early diagnosis of dementia. American Journal of Managed Care 6: 1111–24.

9. Department of Health (2001) National service framework for older people: modern standards and service models. London: Stationery Office.

10. Audit Commission (2000) Forget me not: mental health services for older people. London: Audit Commission.

• Memory assessment service
• Commissioning a memory assessment service for the early identification and care of people with dementia
• Specifying a memory assessment service for the early identification and care of people with dementia
• Determining local service levels for a memory assessment service for the early identification and care of people with dementia
• Assumptions used in estimating a population benchmark
• The commissioning tool
• Ensuring corporate and quality assurance