The East Dunbartonshire Advisory Clinic Model: Better outcomes for people with dementia

East Dunbartonshire is an area in Scotland where citizens generally enjoy a very good quality of life, with relatively low levels of unemployment and material deprivation.  One of the most significant social challenges facing East Dunbartonshire, however, is its ageing population. It is the Scottish local authority area with the highest proportion of older people. Some 21% of the local population are aged over 60 years old, and this is rising sharply (the population aged over 75years is set to increase by 71% by 2024).  There are an estimated 1,957 people living with dementia in East Dunbartonshire in 2013. 

Read how the local council devised a new service model with third sector partners to respond to this challenge.

The Dementia Advisory Clinic model was developed as a response to the challenges in dementia care locally. It is based on the principles of co-production and gives the third sector a critical role in reshaping and delivering services. The model provides enhanced co-ordination of existing activities, whereby third sector partners offer bespoke one-to one information and advice to individuals concerned about dementia, via Dementia Advisory Clinics. These Clinics act as a gateway to specialist services.  The Clinic model is central to the objectives of the national programme ‘Reshaping Older People Services’. It supports people to live independently at home or in a homely setting through the provision of information, advice, support, anticipatory and crisis planning, carers education and support, more informed and confident staff and consistent responses.

The initiative developed out of the work of the East Dunbartonshire Dementia Network, a forum that brings together groups, organisations and members of the community committed to improving the lives of people with dementia, their families and carers. The Network originally functioned as a knowledge exchange with members sharing service updates and was established by a representative of the Scottish Dementia Working Group, a national voice for people with dementia by people who have dementia. It evolved over time to become a forum for collaboration with a focus on co-creation and a shared vision for a new dementia inclusive community.

The clinic model was developed by East Dunbartonshire Council’s Social Work Department in partnership with the Community Health Partnership and three third sector partners, Alzheimer Scotland, Ceartas Advocacy and Carers Link. East Dunbartonshire Council has an established record of investing in support that is meaningful to people with dementia. In 1999 it supported study through the first international MSc in Dementia Studies at the University of Stirling. This study focussed on the views of people with dementia on the things that help them feel included in decisions about their care and provided the framework for the current co-production approach. Ceartas has an established Dementia Group where people with dementia make their views known about local issues. Alzheimer Scotland has forums locally and nationally for interaction with people who have dementia about the type of support that they require. Carers Link similarly supports local carers of people with dementia to make their views known about the issues that matter to them.

Clinics have been delivered in a variety of settings and locations throughout East Dunbartonshire, and include a specific clinic for black and minority ethnic people who have dementia or are concerned about dementia. The clinic model contributes to a more efficient use of existing services through enhanced co-ordination of the existing resources of all of the partner organisations. They deliver the type of advice and support that people with dementia have advised they need and fit around the lives of the person with dementia delivered flexibly and sensitively.

The process of developing and testing the new service model was straightforward in most respects. However, particular time and emphasis was required in:

• Choosing partner providers. From among the wide network of potential service providers there were choices required on who the core operational partners should be. This process was managed within the context of the Dementia Network, ensuring an open and transparent process of developing the partnership. 
• Building a third sector consortium. The collaborative model was able to come together because of existing strong cooperation between statutory organisations and the third sector whereby partners were actively sharing their own resources and co-operating with each other.  Putting together a formal agreement for a number of organisations to work together within a specific service framework did take time but the good practice already happening through the Dementia Network expedited this process.
• Agreeing the service design. It required time and some difficult conversations between partners to agree the optimum service delivery model. Throughout the process partners needed to remain grounded in the relevant policy priorities and expressed service user needs. It was also important to form a service delivery model that played to the strengths of each partner provider. 

Channelling the resources. There were considerations regarding the most appropriate mechanism through which to channel Change Fund resources into testing the new service. In the end one ‘lead’ partner from among the three providers was identified to manage funds, accountable to the Local Authority, with Service Level Agreements formed with the other third sector providers. This again required co-operation among partners.

The new service delivery model created with third sector partners is already having very positive results.  By harnessing resources, East Dunbartonshire Council and Community Health Partnership are now able to:

• avoid several organisations and bodies overlapping and all putting much needed resource into the same tasks on an individual basis;
• draw on greater capacity and resources collectively through partners than were available in-house; 
• test a model of service that is much more flexible and capable of responding to the needs of older people; and
• take a longer-term perspective on what is a key service challenge for the Council and partners. 

The more collaborative approach to the service means that the customer receives the best range of information from the specialist services to cater for the multi-faceted needs that dementia brings to people and their families. Qualitative evidence around the experience of care has been gathered with positive feedback.

Through working to enable people with dementia we promote self-management at an early stage of the condition, more confident carers and anticipatory planning to avoid unnecessary crisis, which contributes to a more efficient use of existing service and additional costs from emergencies.

There has been a significant reduction in hospital delays, with only one person delayed in the year 2012/2013 as a result of Adults with Incapacity issues. There have been no delays as a result of ‘Adults with Incapacity’ issues for over six consecutive months for people with dementia. This can be evidenced through Delayed Discharge reporting mechanisms.

There is regular attendance at clinics with over 200 people attending the range of clinics in the different settings, including hospital venues. A further 1,925 people are working with clinic staff in other settings. Personal plans have been developed in line with the Alzheimer Scotland Five Pillars Model of dementia support and have been implemented in April 2013. We have also increased the numbers of people included on our GP Quality Outcome framework registers (QoF) and the numbers of people who are managing their own care through self-directed support.  Specialist roles including Dementia Champions and Ambassadors have been created throughout East Dunbartonshire.

The Council and its partners have also benefited from the international and national recognition and prestige that the initiative has received. In June 2012 this unique work received a commendation at the International Dementia Excellence Awards in Sydney, Australia. The Clinics are also used as an example of best practice by the Scottish Government’s Joint Improvement Team on models of co-production which support the transforming older people services agenda. In 2013 the model was recognised by the Convention of Scottish Local Authorities (COSLA) and the Association of Public Service (APSE) Excellence Awards.

Furthermore, the Dementia Advisory Model is being supported by the Scottish Government’s Ready for Business programme in developing a model to evidence culture change in this area and in particular in securing added value to the public sector through the third sector. The work is now being further developed through asset mapping and identifying resilience in the context of dementia through a funded PhD.

One of the initial challenges for this innovative approach to dementia care was the need to harness valuable resources to avoid several organisations and bodies overlapping and all putting much needed resource into the same tasks on an individual basis.

Through working with people with dementia the service promotes self-management at an early stage of the condition, more confident carers and planning in advance to avoid unnecessary crisis. This contributes to a more efficient use of existing service and avoids additional costs that arise from emergencies. 

As a result of its innovative service design, the Dementia Clinics only costs a modest £67,000 per annum, funded through the Change Fund held by Ceartas advocacy to ensure that the service user view remains central to the process. There has been a significant reduction in hospital delays, with only one person delayed in the year 2012/2013 as a result of Adults with Incapacity issues.

There is regular attendance at clinics with over 200 people attending the range of clinics in the different settings, including hospital venues. A further 1,925 people are working with clinic staff in other settings.

Personal plans have been developed in line with the Alzheimer Scotland Five Pillars Model of dementia support and have been implemented April 2013.

We have also increased the numbers of people included on our GP Quality Outcome framework registers (QoF) and the numbers of people who are managing their own care through self-directed support.  Specialist roles including Dementia Champions and Ambassadors have been created throughout East Dunbartonshire.

The savings made by each organisation can then be used in other ways to develop new and innovative ways of working. One such initiative is a project developed by East Dunbartonshire where people with dementia in care settings engaged with tablet personal computers to promote self-expression, target loneliness and stay connected to the community.

With the service now performing well and delivering anticipated outcomes, a number of factors have been instrumental in the early success of this new service model:

• Catalytic funding. The availability and time of the Change Fund resources provided the ability to develop and test a new service in partnership with the third sector, with a view to mainstreaming the approach based on the learning. This was vital in being able to reconfigure services and eventually to sustain the approach (investing to save).
• Building on a strong network of support. The approach was grounded in a strong network of interested parties – the Dementia Network – from which the concept was developed. This provided a natural forum from which to design the service, and access to a wide network of expertise, connections, venues, and resources. The initial involvement of all interested parties ensuring widespread local support.
• A driver. The Council’s Older People Team Manager provided a single lead on dementia issues, operating jointly on behalf of Council’s Social Work Department and the Community Health Partnership. This enabled a coordinated response among public agencies. This individual has also been instrumental in driving forward the initiative.
• A partnership of equals. Public and third sector partners have come to the partnership on an equal footing, collaborating in the design of the project and contributing knowledge, capacity, and resources as they can.
• The right third sector partners. Partners emerged that had the appropriate track record and specific specialisms within the dementia field. This supplemented the knowledge and capacity held by the Council and Community Health Partnership. All of the partners are committed to training and learning to ensure that the service is based on research and best practice.
• Close working relationships. Close personal and professional relationships based on trust developed between partners. This built on pre-existing partnership working between senior staff in the partner organisations. 
• Enabling the right solution. Partners were willing to put their own organisational interests to one side to find a solution that was right for people with dementia in East Dunbartonshire. The Council’s Social Work department demonstrated a willingness to think and act differently, facilitating a creative solution to emerge.    
• A robust service design. Partners spent time designing a service capable of meeting public service priorities, grounded in the needs of service users, and capable of delivering transformational change. The service was based on a clear specification and on the basis of soundly articulated and measurable outcomes. 

Website of East Dunbartonshire Council on services and advice for people living with dementia: https://www.eastdunbarton.gov.uk/health-and-social-care/services-adults-and-older-people/dementia