Hospitals have made important changes to improve dementia care, but staff say more support is needed.
Hospitals in England and Wales have made many positive changes aimed at making hospitals more “dementia-friendly”, an audit shows. Overall nearly 70% of carers rated care as excellent or very good, and 75% said that the person with dementia was definitely treated with respect by staff. Many more hospitals are providing dementia awareness training to all groups of staff, and 96% have a training framework for dementia care, up from 23% in the first round of audit in 2011. Nearly all hospitals (94%), have created dementia “champions” to lead change and support staff, following a recommendation made in Round 2. Staff however said they could not always access specialist support, especially out of hours.
Nineteen percent of staff surveyed said that patients with dementia had nutritional needs met only some of the time, and five percent said their needs were not met. Three quarters of staff (73%) said they could obtain food 24/7 for their patients. Food outside of regular mealtimes is necessary for people with dementia as many patients forget to eat or only eat little and often, because dementia has disrupted their sense of routine.
The National Audit of Dementia, commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP), reviewed case notes of 10,047 patients with a diagnosis or current history of dementia and questionnaires from 14,416 staff and 4664 carers from 199 hospitals across England and Wales. The audit is managed by the Royal College of Psychiatrists in partnership with organisations representing healthcare professionals, people with dementia and carers.
The audit also found:
Personal information on care and communication needs of people with dementia could not always be accessed by staff, and over half of carers thought staff could be better informed. A spot check carried out on selected wards found that half of the patients did not have the sheet with this information available, although almost all hospitals have systems to collect it.
People with dementia were not always consulted about life changes, as one third (34%) of case notes recording conversations with social workers about potential transfers from family home to care home showed no record of consent to begin this process from patients (or proxies where patients did not have capacity to consent).
Less than half of patients had a recorded initial assessment for delirium - a state of disorientation and confusion that can make dementia more rapid and even be fatal. People with dementia have a fivefold risk of developing delirium. Forty-five percent of patients were screened for the condition, compared to 38% in the 2013 audit.
Professor Mike Crawford, Director of the Centre for Quality Improvement at the Royal College of Psychiatrists said: “There are some encouraging improvements at a national level but achievement in improving care can vary between hospitals. For example, previous audits have recommended recording basic personal facts about a patient to aid care, but we are still not seeing this being consistently implemented.
“Something as simple as filling in a form with personal facts about a patient’s care cannot be overlooked when we know that dementia affects memory and can lead to severe communication difficulties.”
Key recommendations in the report are:
1. The Chief Executive Officer should ensure that there is a dementia champion available to support staff 24 hrs per day, 7 days per week. This could be achieved through ensuring that people in roles such as Site Nurse Practitioners and Bed Managers have expertise in dementia care.
2. National Commissioners should propose a national programme aimed at embedding the collection, sharing and use of person centred information with a clear expectation this information will follow the patient between providers.
3. Chief Executive Officers and commissioning services should make sure when tendering for new catering contracts that access to finger foods and snacks 24 hours a day is included.
4. The Safeguarding Lead should ensure staff are trained in the Mental Capacity Act, including consent, appropriate use of best interests decision making, the use of Lasting Power of Attorney and Advance Decision Making. Training should cover supportive communication with family members/ carers on these topics.
5. The Medical Director should ensure that hospitals have robust mechanisms in place for assessing delirium including appropriate assessment on admission and discharge with full recording of results.
Dr Oliver J Corrado, Consultant Physician to the Audit, Consultant Geriatrician and 'Dementia Champion', Leeds Teaching Hospitals NHS Trust said: “It is gratifying that the National Audit of Dementia has shown that hospitals and Trusts have continued to make significant improvements in the care of people with dementia. In particular, almost all now have a designated Lead Clinician to champion the care of people with dementia and have established regular groups and meetings to improve the care of this potentially vulnerable group of people. Many have also signed up to ‘John’s Campaign’ to further improve patient care and support carers.
However the audit has shown that there are some areas which could improve further. It is important that any person with dementia admitted acutely to hospital has their cognition (level of confusion) assessed routinely and that the possibility of delirium is excluded. Staff education and training in dementia has improved but could be even better and should encompass delirium as well and it is vital that patients’ nutritional needs are met. But a lot of progress has been made, it is very reassuring that 70% of carers felt standards of care were at least ‘very good’ and that patients were treated with respect by staff. I very much hope that this report will stimulate and encourage health service providers and commissioners to strive for even higher standards of care for people with dementia in future.”
Beth Swanson Lead Nurse Dementia, South Tees Hospitals NHS Foundation Trust and Consultant Nurse to the Audit said: “Over the past three rounds of the National Audit of Dementia we have seen significant improvements made by hospitals to improve care and experience for people with dementia. There is clearly more still to do. One key finding is that hospitals are developing good policies and guidelines for people with dementia but that these policies don’t always get fully put in practice. We can see that in feedback from carers and from staff. On the whole, there are notable markers of progress which should be celebrated. With continued investment and leadership across the NHS, care and experience for people with dementia will continue to improve”.
Notes to editors
About the Royal College of Psychiatrists
1. We are the professional medical body responsible for supporting over 18,000 psychiatrists in the UK and internationally.
2. We set standards and promote excellence in psychiatry and mental healthcare.
3. We lead, represent and support psychiatrists nationally and internationally to governments and other agencies.
4. We aim to improve the outcomes of people with mental illness, and the mental health of individuals, their families and communities. We do this by working with patients, carers and other organisations interested in delivering high quality mental health services.
About the National Audit of Dementia
The National Audit of Dementia is commissioned by HQIP (see below) and managed by the Royal College of Psychiatrists in partnership with:
Royal College of Nursing
Royal College of Physicians
British Geriatrics Society
Dementia Action Alliance
Representatives of people living with dementia and carers
This is the third round of audit. Data was collected between April and November 2016. One hundred and ninety-nine hospitals in England and Wales took part in the audit and were asked to complete four elements:
A hospital level organisational checklist
A retrospective casenote audit with a target of a minimum of 50 sets of patient notes
A survey of carer experience of quality of care
A staff questionnaire on providing care and support to people with dementia 1
Ninety eight percent (199/203) of hospitals eligible to participate across England and Wales submitted data for all or part of the audit. Carer and staff questionnaires are new elements in this round of audit. Round 2 of the audit reported in 2013.
About HQIP, the National Clinical Audit Programme and how it is funded
The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, and in particular to increase the impact that clinical audit has on healthcare quality in England and Wales. HQIP holds the contract to manage and develop the National Clinical Audit Programme, comprising more than 30 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions. The programme is funded by NHS England, the Welsh Government and, with some individual audits, also funded by the Health Department of the Scottish Government, DHSSPS Northern Ireland and the Channel Islands.
Delirium is a state of acute confusion and disorientation which worsens recovery from illness and can be fatal. Patients can hear voices, hallucinate, experience rapid mood changes and become incoherent in conversation. For more information, watch the video on YouTube.
A copy of the Executive Summary report is attached to this email. To request a full copy of the report, email NAD@rcpsych.ac.uk.
Improvements to care made by hospitals – case study – Homerton University Hospital
On joining Homerton University Hospital in East London in 2014, Emma Higgins, the Lead Nurse for Dementia Care, found that there were variations between wards about whether or not carers of people with dementia could stay beyond visiting times.
Emma said: “People with dementia can experience increased levels of agitation and distress in the evening and this is just when it might be helpful to have someone who knows the person with dementia well, stay. It can also be helpful for carers or people who know the person well to support with communication and emotional needs. There was a clear need to have a consistent system in place across the entire hospital.”
The ‘Carers Passport’ was launched by the Trust in May 2016 during National Dementia Awareness Week. The ‘Passport’ allows carers to visit a ward at all times including out of hours. Carers now have the opportunity to take part in mealtimes, personal care and to support the person with dementia during periods of stress and anxiety. The introduction of the ‘Passport’ sits alongside the work the Trust have been doing with carers to encourage their involvement and to offer them support, and follows the Royal College Nursing and Carers Trust ‘Triangle of Care: Carers Included: A Guide to Best Practice in Dementia Care’, which was developed in recognition of the need to improve carer involvement in hospital settings.
Emma said “Homerton is committed to providing high quality care and support for our older patients and their families and carers. We recognise that carers are key members of the team to support each individual with dementia and we understand the importance of involving carers in all aspects of caring for people who have dementia.”
To learn more about the work in this hospital please contact Emma Higgins on
Emma Higgins, Lead Nurse Dementia Care