As part of the Memory First project, patients in Stafford and Cannock with dementia are assigned a care facilitator to provide support for them and their families and carers, to help them to access the services and support they need.
Care facilitators are employed by St Giles Hospice and Douglas Macmillan Hospice and funded by GP First, a consortium of all 41 practices across Cannock and Stafford.
The pilot programme incorporates locally-based memory clinics, led by a consultant psychiatrist or an advanced nurse practitioner, with social care services, charities and end of life support. It aims to ensure, where possible, that patients are able to access care in their own community under the care of their GP with expert support from South Staffordshire and Shropshire Healthcare when needed.
Care facilitator Tracy Malcolm said: “I think the service is already making a big difference. That’s clear just from the really positive feedback we are getting from patients, their relatives and carers.”
“I think a lot of that is down to the fact the patient has the same person coming to see them all the time,” she explained. “That continuity of care can be vital especially to patients experiencing dementia and to their family and carers.”
“People are just so happy to have someone who will go out to them and spend some time with them showing a genuine concern and listening to them,” she adds. “It’s a very rewarding job, especially with the feedback as positive as it is.”
Two teams of care facilitators operate across Cannock and Stafford and the surrounding area, taking referrals from GPs in the area and then contacting patients directly, before going out to their home to carry out an assessment and organising a personalised care plan.
“We organise everything for them basically,” said Tracy. “Booking them into a memory clinic at a nearby venue using an electronic calendar, as well as making sure the patient and their carer are aware of all the care available to them, signposting them to services like Alzheimer’s Cafes, the Carers Association, MAZE, Respite Care and any websites or online resources they can access for support.
Valerie Burgess and her husband John have both benefited from the new service. John was first referred into the service by his GP after the couple grew concerned that his short-term memory was diminishing.
Valerie commented: “It’s been a really good experience for both of us. Tracey came to the house to see us and explained how it all worked and what she was going to be able to do to help us. She did a short assessment on John and at the end of it referred him to a consultant.
“One of the best things about the service has been that Tracey has followed us through the process since day one. That made a big difference to both of us but especially to John.
“When you’re suffering from something like short-term memory loss like John was, having someone professional with you there all the way through the process, from your assessment to those consultant appointments – which Tracy attended with us – is really reassuring.
“It can be quite worrying thinking you have Alzheimer’s. I knew John was anxious, but I don’t think I realised how anxious he was until we went through the process. Tracy understood that and how difficult it can make life when you think you are being ignored or thinking people don’t understand what you’re trying to say.
“Our experience of the whole service has been that it’s been really supportive and helpful all the way through. Having Tracey come to us in our own home and the appointments somewhere local made the whole process so much easier as well. If we had had to travel, with the worry that came with everything, it would have been so much more difficult.”
John said the support he and his wife had received from Tracey had been “absolutely marvellous”.
“She’s been fantastic,” he said. “She made us feel so comfortable every step of the way. It made me feel that much better to know I had the same person looking out for me at every step.”
Greatest impact on patient care
The Memory First pilot developed by Cannock and Stafford and Surrounds Clinical Commissioning Groups in partnership with South Staffordshire and Shropshire Healthcare NHS Foundation Trust and led by GP First, was awarded £80,000 of funding in the NHS Innovation Challenge Prize earlier in the year.
GP, Dr Ian Greaves, who led the development of the service, said: “With an ageing population the old models of dementia care are not sustainable. Keeping the patient under the responsibility of the GP, supported by secondary care expertise, when needed, is a real shift.
“The engagement of all 162 GPs across the 41 practices was key. We highlighted dementia as the area in which we could jointly have the greatest impact on patient care and the health economy.”
Andy Donald, Chief Officer for Stafford and Surrounds and Cannock Chase Clinical Commissioning Groups, said: “With an ageing population putting extra pressures on health care services, putting the patient at the centre of their care, we have to start doing things differently, more innovatively. Part of this scheme uses smartphone apps to help patients and their families to monitor their care which is just one example of the innovative approach we’re taking.”
Jeanette McCartney, Director of Clinical Services at Douglas Macmillan, said: “The Memory First model for providing care for patients in the primary care setting, truly supports the patient and their carers by providing holistic support both pre and post diagnosis.”
Emma Hodges, Deputy Chief Executive of St Giles Hospice, added: “We were delighted to be able to lend our support to this innovative programme of care. Although the care facilitators are funded by the NHS, we were able to use our expertise to identify and recruit the very best people for the job.”