Category Archives: Book

Book launch for ‘Enhancing health and wellbeing in dementia’: final timetable

The aim of this event is to celebrate the successful publication of my book “Enhancing health and wellbeing in dementia: a person-centred integrated care approach” by Jessica Kingsley Publishers on 19 January 2017.

The presentations for my book launch are finally confirmed as follows. This is a free event, private by invitation only, free and with no funding. All places have now been finally allocated.

A book signing will take place at 1 pm. Copies of Jessica Kingsley Publishers books will be available on the afternoon, including Kate Swaffer’s “What the hell happened to my brain?” (Jessica Kingsley Publishers, 2016). I will ensure that, if I achieve permission from the relevant parties, that items from the afternoon are published on Vimeo after the event.

I am delighted to be joined by Kate Swaffer as well as 49 other delegates.

Event timetable

1.00 Book signing

 

1.40 Introduction to afternoon presentations

Lisa Rodrigues CBE, writer, coach and mental health campaigner, www.LisaSaysThis.com

 

1.50 Enhancing health and wellbeing in dementia: a person-centred integrated care approach

Shibley Rahman

 

2.10 Co-production, human rights and citizenship

Alison Cameron, citizen journalist and activist

 

2.30 Technology and supporting well

Maneesh Juneja, Digital Health Futurist, MJ Analytics

 

2.50 Living alone at home, Jo Moriarty, Senior Research Fellow and Deputy Director, SCWRU

 

3.10 Care homes and promoting wellbeing

Yvonne Manson and Joe Walker, Dementia consultants, Balhouise Care Group

 

 

3.30 Networking Break (with afternoon tea and biscuits)

 

3.50 Preventing excess disability through psychological approaches: a clinical psychologist’s view

Reinhard Guss, Chair, British Psychological Society, Faculty of the Psychology of Older People

 

4.10 Introduction to person-centred acute care in hospitals

Shibley Rahman

 

4.20 Acute hospitals and caring well: a clinical nursing specialist’s view

Lucy Frost, Dementia lead, Sussex Community NHS Trust

 

4.40 Hospices and dying well, Sarah Russell, Head of Research and Clinical Innovation Hospice UK

 

5.00 pm Discussion

One of the questions asked in the final scope of the new NICE guidance currently in development [please see below] is, “How should care be arranged to optimise the health and wellbeing of people living with dementia and their informal carers?”  This will be the question for our 30 minute discussion in my book launch.

I am privileged that the discussion event will be chaired by friend and colleague Kate Swaffer, finalist in this year’s Australian of the year competition, CEO and co-founder of Dementia Alliance International, and member of the World Dementia Council.

There are fifty delegates in attendance, including myself, with a very wide range of backgrounds and experiences all relevant to the dementia field. An invitation to attend was sent out and tickets were allocated on a first come first served basis. A waiting list was in operation. There was no problem in filling the places as this free event was massively oversubscribed.

I feel that I have been able to cover a huge amount of material relevant to English dementia policy, including in my previous books “Living better with dementia: good practice and innovation for the future” (Jessica Kingsley Publishers, 2015) and “Living well with dementia: the importance to the person and the environment” (CRC Press, 2014). I was honoured that my very first book won best book of the year award for health and social care in the BMJ Awards in 2015.

Reflecting best practice

The NICE guideline “Dementia: assessment, management and support for people living with dementia and their carers” currently in development will update the NICE guideline on Dementia (CG42).

The final scope is published here.

The key themes of this guidance mirror closely my new book ‘Enhancing health and wellbeing in dementia: a person-centred integrated care approach’, published by Jessica Kingsley Publishers in January 2017.

They are, as stated in the Final Scope:

1. Ethics, consent and advance decision-making
2. Training and development of health and social care staff
3. Recognition (signs and symptoms, risk factors)
4. Assessments for suspected dementia
5. Diagnosing dementia
6. Slowing the progression of dementia
7. Identifying dementia subtypes
8. Intercurrent illness in people living with dementia
9. Comorbidities and multimorbidities
10. Risk management and how it can support people living with dementia to avoid harm and maintain independence
11. Interventions to maximise the health and wellbeing of people living with dementia who experience changes in cognitive function
12. Interventions to maximise the health and wellbeing of people living
13. Assessing the needs of carers
14. Psychosocial interventions for carers of people living with dementia
15. Integrated health and social care
16. Inpatient services
17. Palliative care, pain relief and care at the end of life for people living with dementia

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How should care be arranged to optimise the health and wellbeing of people living with dementia and their informal carers?

The NICE guideline “Dementia: assessment, management and support for people living with dementia and their carers” currently in development will update the NICE guideline on Dementia (CG42).

The final scope is published here.

The key themes of this guidance mirror closely my new book ‘Enhancing health and wellbeing in dementia: a person-centred integrated care approach’, published by Jessica Kingsley Publishers in January 2017.

They are, as stated in the Final Scope:

1. Ethics, consent and advance decision-making
2. Training and development of health and social care staff
3. Recognition (signs and symptoms, risk factors)
4. Assessments for suspected dementia
5. Diagnosing dementia
6. Slowing the progression of dementia
7. Identifying dementia subtypes
8. Intercurrent illness in people living with dementia
9. Comorbidities and multimorbidities
10. Risk management and how it can support people living with dementia to avoid harm and maintain independence
11. Interventions to maximise the health and wellbeing of people living with dementia who experience changes in cognitive function
12. Interventions to maximise the health and wellbeing of people living
13. Assessing the needs of carers
14. Psychosocial interventions for carers of people living with dementia
15. Integrated health and social care
16. Inpatient services
17. Palliative care, pain relief and care at the end of life for people living with dementia

One of the questions asked in the final scope is, “How should care be arranged to optimise the health and wellbeing of people living with dementia and their informal carers?”  This will be the question for our 30 minute discussion in my book launch.

The presentations for my book launch will be as follows. A book signing will take place at 1 pm. Copies of Jessica Kingsley Publishers books will be available on the afternoon, including Kate Swaffer’s “What the hell happened to my brain?” (Jessica Kingsley Publishers, 2016). I will ensure that, if I achieve permission from the relevant parties, that items from the afternoon are published on Vimeo after the event.

1.50pm Enhancing health and wellbeing in dementia: a person-centred integrated care approach
2.10pm Co-production, human rights and citizenship
2.30pm Technology and supporting well
2.50pm Living alone at home
3.10pm Care homes and promoting wellbeing
3.50pm Preventing excess disability through psychological approaches: a clinical psychologist’s view
4.10pm Introduction to person-centred acute care in hospitals: cultural considerations
4.20pm Acute hospitals and caring well: a clinical nursing specialist’s view
4.40pm Hospices and dying well

There are fifty delegates in attendance, including myself, with a very wide range of backgrounds and experiences all relevant to the dementia field. Inevitably, I am sad in that this is my last entrance into the dementia field. I would like to say it has been a pleasure, but my views on this are well known.

I feel, notwithstanding, that I have been able to cover a huge amount of material relevant to English dementia policy, including in my previous books “Living better with dementia: good practice and innovation for the future” (Jessica Kingsley Publishers, 2015) and “Living well with dementia: the importance to the person and the environment” (CRC Press, 2014). I was honoured that my very first book won best book of the year award for health and social care in the BMJ Awards in 2015.

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My final book on dementia: on a person-centred approach to enhancing health and wellbeing

The title of the book reflects the fact every person has a human right to health, and that wellbeing is a critical part of wellbeing. It was published earlier this month by Jessica Kingsley Publishers (page including pre-publication reviews here).

 

Many of the issues raised in the book coincidentally have been raised in the draft World Health Organization global ‘draft action plan’, worth a look at here http://apps.who.int/gb/ebwha/pdf_files/EB140/B140_28-en.pdf, published 23 December 2016.  It is felt that while this document is not ‘perfect’ it is a good start. For example, the palliative care approach is specifically signposted in clause (56).

 

People are entitled to the best of care regardless of setting – for example, Dementia Care Mapping™ (DCM™) has been used as an observational tool which has been designed to be used within formal care settings such as care homes, nursing homes, day services and hospitals. This book is, in fact, in part dedicated to Dawn Brooker, and frequent references are made in the text to Tom Kitwood. The book is also dedicated to Martin Rossor, national director for dementia research, for whom I worked in 2003. I do not of course wish to speak about the specialist area of personhood as I feel that would be entirely inappropriate.  An excellent book on this area, however, is “Person-Centred Dementia Care, Second Edition: Making Services Better with the VIPS Framework”, by Dawn Brooker and Isabelle Latham, also published by Jessica Kingsley Publishers https://www.amazon.co.uk/d/Books/Person-Centred-Dementia-Care-Second-Framework/1849056668.

 

 

My book is intensely evidence-based but not in a way, I hope, which is off-putting to the primary audience – who are not commissioners, but persons living with dementia and carers. I certainly believe that it is the primary duty of researchers at least to think about the basic translation of research into practice. Many of the interventions and service developments will ultimately rely on this.

 

Thankfully, there are people in care settings who think very carefully about the environment of care, for example helping carers identify, find solutions and create a care culture to overcome mealtime eating problems in dementia. ‘Working with’ collaboratively not working to patients has been a fundamental change in attitude for organising services and research, and the fundamentals of co-production are intimately linked to citizenship and human rights. And we do need to ensure people get access to the right care at the right time. For example, there can be difficulty seeing your GP, or dementia care is an increasingly important strategic consideration for palliative and end of life care providers, including hospices. It is noteworthy that, through working in partnership with their local community and care providers, hospices can ensure that the best of hospice care is extended to everyone affected by a diagnosis of dementia within their local community.

 

 

Responding to the challenge

 

The NHS Five Year Forward View, the current strategic ‘masterplan’ of the NHS, emphasises integration, personalisation and empowerment:

 

There is broad consensus on what the future needs to be. It is a future that empowers patients to take much more control over their own care and treatment. It is a future that dissolves the classic divide, set almost in stone since 1948, between family doctors and hospitals, between physical and mental health, between health and social care, between prevention and treatment.”

 

Chapter 1, Five Year Forward View, 2014 (https://www.england.nhs.uk/ourwork/futurenhs/nhs-five-year-forward-view-web-version/5yfv-ch1/)

 

Dementia has been the target of much stigma from society, and despite the rhetoric of ‘parity of esteem’, much more can be done to understand the physical and mental health needs of persons living with dementia.  Recent initiatives such as ‘dementia friendly communities’ have identified that dementia is unlikely to be the only medical condition a person might live with long-term, and all that communities should be inclusive and accessible. Preventing certain people from being lonely and isolated has immeasurable social and well-being benefits for the individual. There are some amazing ‘dementia friendly’ initiatives – for example, a visit to the theatre can have a profound impact on people living with dementia and their families. It is crucial that all initiatives are culturally inclusive too, including raising awareness and promoting understanding of dementia within culturally diverse communities, which might mean physically visiting day centres, community groups and religious centres to talk about dementia and tackling the stigma that surrounds dementia.

 

Dementia is thought to be the most feared condition in adulthood, and this can affect diagnosis-seeking behaviours as well as the message that ‘nothing can be done’ after a diagnosis. A person never receives a diagnosis of dementia alone; so, understanding how the diagnosis impacts on that person and those closest to him or her is of fundamental importance. What happens after a diagnosis can be incredibly complex, and we need health and social care systems which are flexible, adaptable, and correctly resourced to cope. Interventions for living well, supporting well or caring well are not just medical, but can also be psychological (cognitive or behavioural) – and might prevent further decline. Professionals can unfortunately instil a feeling of helplessness in a person diagnosed with dementia, referred to within Kate Swaffer’s construct of ‘prescribed disengagement’™.

 

I propose in the book that there are key demands of integrated care which I picture in the Preface as spokes of an umbrella.

umbrella

 

‘Responding’ to a new diagnosis of dementia needs new, flexible ways of adapting.

 

Take for example the description of Wendy Mitchell – living with dementia:

 

However, I’m also hoping I can convey that, although we’ve been diagnosed, people like me still have a substantial contribution to make; we still have a sense of humour; we still have feelings. I’m hoping to show the reality of trying to cope on a day-to-day basis with the ever-changing environment that dementia throws at those diagnosed with the condition. Living well with dementia is all about adapting. Adapting to new ways to enable us to live better for longer with dementia.”

 

(Wendy Mitchell’s blog – “Which me am I today?” https://whichmeamitoday.wordpress.com)

 

Dementia is a prevalent condition, but trends are complicated due to the effect of risk reduction work, the numbers of our ageing population and improved rates of diagnosis nationally. There are approximately about 900,000 people currently living in the UK with dementia. However, the nature of the condition means that managing it can pose unique and sometimes difficult issues, both in the community and in other care settings, and “dementia is everybody’s business” meaning that this is a widespread societal concern, not just the caring professions.

 

With the right support and opportunities, people with dementia and carers can successfully communicate, engage, participate and continue to be part of relationships and communities, and this is no matter how advanced their dementia.

 

This third book provides some of the ingredients to a recipe providing the change for people living with dementia and carers would be supported in a holistic, person-centred way. It is impossible to deliver person-centred care in an exceptional way, without staff feeling properly supported and empowered to fulfil their roles. The language we use is a critical aspect to this. Notwithstanding, there is a strong sense of interconnectedness in the ‘dementia’ sphere, and people in person-centred integrated care tend to be aligned to certain values of openness, trust, valuing difference, innovation and collaboration.

 

There have been enormous strides in how people living with dementia are supported, however there is always more to be done. Technology now embraces telehealth, telecare, mobile health, telemedicine, e-health, smart home technologies and Internet of Things, but is increasingly including informatics (including electronic health and care records), big data, artificial intelligence as well as health and care robotics. Digital technology and social networks provide some of the most powerful tools available today for building a sense of belonging, support and sharing among groups of people with similar interests and concerns.

 

Despite the lack of ‘caring well’ in the NHS Transformation Network, presumably subsumed under ‘living well’ and ‘supporting well’, my book is worth reading with their construct in mind. It can be viewed on this hyperlink: https://www.england.nhs.uk/mentalhealth/wp-content/uploads/sites/29/2016/03/dementia-well-pathway.pdf.

 

dementia-well-pathway

 

Cost pressures are requiring providers to find new ways of developing a compassionate, capable and competent, yet affordable workforce. Furthermore, both specialist and generic services can struggle to cope with the increased demand upon services. We know there’s a ‘funding gap’ referred to the ‘Five Year Forward View’. But this should be the driver behind transformation plans. Many people involved in dementia care feel there’s also a ‘time gap’ – people with dementia need more of it and hospitals don’t seem to have any. The experience of someone with dementia is often affected by how well the discharge out of hospital goes. For example, a specialist occupational therapist to make sure we got the discharge process right for dementia patients and focussed on safe transfer of care from hospital into the community. Many would like to give a commitment to really making time for residents in its care homes and houses allows all to be treated as individuals, as this provides an environment where residents who are living with dementia can improve their quality of life.

 

The pressures on residential care are enormous. Some care homes face insolvency. A person with dementia is an individual with individual needs and changes to the environment can affect that person, and these could include the health and wellbeing of staff.  The potential problem with framing promoting wellbeing as ‘activities’ is that the focus instead of being on the person becomes focused on the task. Promoting wellbeing might advance ‘life skills’ and improve mental condition, helping and inspiring participants to reminisce and rediscover aspects of their lives. Ideally then all ‘activities’ would be based on the interests, desires and wishes of our residents, and might include tai chi, massage, cream tea, arts, singing, flower arranging, or music. We know that communication is incredible important. Stories can strengthen emotional links between generations, and help to mitigate against negative effects of the combination of dementia, depression and loneliness in communities.

 

We live in exciting times.

 

 

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Review: Diagnosed with Alzheimers or Another Dementia by Kate Swaffer and Lee-Fay Low

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Diagnosed with Alzheimers or Another Dementia, 1 Sep 2016, by Kate Swaffer and Lee-Fay Low

Book available here

I loved reading this up-to-date book, and this title is essentially a ‘must read’ whatever your connection to person living with dementia might be. This relatively new book is an essential read if you wish to familiarise yourself with the key issues in Alzheimer’s disease and other dementias. As the authors explain, you might have received a diagnosis yourself, or somebody close to you has. And therein lies the first source of power of the book. This is a book partly written by Kate Swaffer, possibly the world’s leading advocate in dementia living with a dementia herself. There are few books which meaningfully discuss the issues of living with dementia from a contemporary rather than historic perspective, for other people with dementia and people in a caring rôle, from somebody who herself has met thousands of people with dementia as a world leader. Though Kate is only one person living with dementia, and Kate would not dare to pretend to be the representative of all 49 million people living with dementia in the world, Kate’s contributions are clearly identifiable to me as having enormous gravitas and immense accessibility. Having said that, however, Kate happens to be an exemplary rôle model.

I found myself noticing certain things about the book, having written three books myself. This particular title is far better than anything that I could’ve written. Firstly, this book is not cluttered or slowed down by loads of references. This is great, and makes the book in fact highly enjoyable to read. That does not make the book a stream of consciousness or informed opinion. Here are two authors who know what they are talking about, Kate Swaffer and an Associate Professor Lee-Fay Low. The writing style of the whole book is seamless and elegant, and does not come across as a clunky chain-letter with vastly different writing styles from the two authors. The tone of the book is infused with a deep interest and passion in the humanity of what it is like to live with dementia, which would have been simply impossible from an authorship not living with dementia. The book – as it happens – accurately reflects the current global literature on dementia, as I know it, but I think will help to guide the future of the shape of the global literature. The big bonus of this book is that it will go a huge way to fight the societal stigma that surrounds the dementia experience for many. In the context of the brilliant contemporary drives for ‘dementia friendliness’ (and genuine inclusion), this is wonderful.

Writing a book if you live with dementia is the ultimate form of ‘empowerment and engagement’ you could provide. This book can be read equally well by a person who has received a diagnosis of dementia himself or herself, a carer, an academic, practitioner/professional, or otherwise. The discussion of what caring means is brilliant, and I particularly loved the discussion of ‘backup brain’ as an alternative to the word carer. This perspective is entirely in keeping with viewing dementia as a condition which provides neurocognitive rehabilitation potential, and the book does not shy away from great tips about dealing with dementia you would find difficult to find elsewhere. There’s a great section on global myths surrounding dementia, and an impressive discussion of Kate’s original contribution to the field – prescribed disengagement™. There’s a strong human rights and disability activism twang to the book, and I couldn’t turn the page without learning something new (for instance autoethnographic approaches to self-reflection in living with dementia, neuroplasticity and learning in dementia). All of these sections are woefully under-represented in other guides and books to dementia, and provide a much-needed refreshing and original read.

I don’t think you must live in Australia to benefit from the book, though the signposting of services is complete if you do happen to live in Australia. But this is the perfect book to have if you’ve been newly diagnosed with dementia wherever you are. I think there are too many books, written by medics for medics for example, which really do not address the needs of persons with dementia or backup brains, and this book fills that critical void. It’s incredibly reasonably priced, which means that the primary aim of this book is clearly to educate as many people as possible – in modern times, this is thoroughly admirable.

I would definitely recommend this book to anyone, ranging from any members of the public who want to know what ‘dementia’ is (it contains some complicated areas brilliantly explained too including types of dementia and both pharmacological and non-pharmacological interventions), to current health professionals wanting to brush up on their knowledge and relevant attitudes, behaviours and skills. This book gets straight to the nitty-gritty of the diverse range of topics of dementia, and refreshingly has no sense of ‘me, me, me’ coming from the authorship. Can you learn as much about dementia through other routes? My answer is: definitely not; but it’s true that you should learn as much as you can about dementia from anyone or anywhere, particularly from other leaders living with dementia. Is it a book you should at some stage meet in your exploration of dementia: I’d humbly submit, definitely.

Dr Shibley Rahman
@dr_shibley

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The desperate need for ‘dementia friendly communities’ in England to up their game

friends

As such, whilst “dementia friendly communities” have a clear brand identity and value to the Alzheimer’s Society and Alzheimer’s Disease International, it is concerning that there have only been thirteen papers ever in the peer reviewed literature specifically looking at the term including one review from 2016.

The problem with its adoption as a marketing brand is that it has largely escaped constructive criticism, particularly from commissioners who are not particularly familiar with people with dementia, carers, or the literature.

Whilst it is true that not all perspective on living a life with dementia or being a carer should necessarily viewed through a prism of the health and social care systems, it is intuitive the these should not be airbrushed out of the discussion, even if that would not particularly perturb Big Society, its brand ambassadors or powerful grant lobbyists. The NHS and social care systems are not getting adequate funding matched to demand, even if one views that ultimately the ‘better bang for your buck’ would be served by new models of care heading towards a US style of accountable care organisations.

The newly published Draft Action Plan on Dementia by the World Health Organisation, published just shy of Christmas 2016, is an important contribution, which takes us a lot further. My beef with the document is that it doesn’t really add up. The “prevention” arguments need to be done with extreme caution. There is a ‘history’ of prevention in medicine as being seen as the more profitable end of healthcare provision. See for example the famous lobbying of Nixon for the 1973 HMO Act. And the arguments for successful prevention can be overstated. If for example you believe that a high level of education can protective against dementia, this in itself does not explain why Oxford graduates Margaret Thatcher and Harold Wilson went on to develop dementia. There is, however, probably something in the prevention drive, in that the MRC CFAS study of epidemiology of Cambridge strongly points to successful targeting of vascular risk factors being able to reduce the incidence of dementia.

The WHO Draft Action Plan is further problematic for England as it takes about universal coverage for NHS and social care (the latter is clearly not the cause being means tested and now being subject to considerable local authority rationing). Furthermore, if it involves a rôle for private insurance system, you can immediately see the problem of insurance packages for dementia, even if you have the most basic knowledge of insurance law. That is, an insurer will want to make voidable any insurance contracts where the person being insured has not been complete or fraudulent in specifying risky behaviours for dementia when he or she took out the insurance package. Insurance companies are of course scrupulous about paying out, as we know from the US jurisdiction. And you also can’t directly sue the insurer.

That aside, it is clear that ‘dementia friendly communities’ needs a revamp. As acknowledged, there are many different forms of dementia with different manifestations according to how brain function has been affected. The actual diagnosis is a moot point often, with many diagnoses being ultimately being called ‘mixed’. The term ‘friendly’ is a nonsense, in that one would be hard pushed to advocate a campaign called ‘dementia nasty communities’. And we don’t know how big a community is, although we do know from the initial guidance of the Big Society which falls into the timeline of dementia friendly communities in the England that communities are large enough to drive local community action, decreasing the need for expensive State-driven intervention. What we have seen in England of course is relative draconian cuts in the NHS and social care, while the brand of the Alzheimer’s Society and its chief proponents have gone from strength to strength.

The original definition of the ‘dementia friendly community’ in England by the Alzheimer’s Society completely failed to address two extremely important issues. Firstly, the independent living argument was made with barely any reference to the impact of disability on loss of independence, and yet this was precisely the argument from the WHO Aged Cities work which predated the English dementia friendly communities. The effect of this was to ignore completely dementia as a disability clearly stated in the regulations to the Equality Act (2010), and strongly alluded to in the preamble of the United Nations Convention of Rights for Persons with Disabilities. Secondly, the human rights argument, with at its heart protection of individual against excesses of their of the State (e.g. lack of dignity in dementia care, excess surveillance in care homes, mitigation against physical restraint), was utterly lost in the English version, though the Scottish version did well to enmesh the PANEL human-rights based approaches in its policy.

The emphasis in the Alzheimer’s Society version is clearly one which benefits the economy, in keeping with the Big Society. Not everyone with dementia wishes to see themselves as ‘economically productive’. Besides, if you took out the hard work done by unpaid carers, the economy would implode under the weight of unmet needs. Carers are absolutely pivotal in getting the diagnosis and management of people with dementia right, as well as improving their wellbeing. On a practical basis, the carer has an invisible hand on the timing of when crises happen, or when a person with dementia may have his or her needs better catered for by a residential care settings.

You don’t see much of carers, say compared to high street banks, in the Alzheimer’s Society ‘dementia friendly community’. High Street Banks can easily all very well market themselves as ‘dementia friendly’, creating competitive advantage through a ‘nudge’. But that’s all it is – marketing, if the customer experience does not actually improve. We do not know how many outcomes have realistically been produced. For example, for all the millions of pounds which have been pumped into ‘Dementia Friends’, why is it that newspaper headlines are incessantly using the terms ‘dementia victims’ or ‘dementia sufferers”? It is as if there is absolutely little accountability on the ‘return of investment’ of this initiative, to a large extent funded by the taxpayer with money leaching into marketing agencies thereafter.

It is therefore a substantial improvement that cross-cutting themes in the new WHO Draft Action on Dementia include improving the human rights of persons with dementia, empowerment and engagement of people with dementia and their carers. The NHS England Transformation Network has the appearance with an emperor with no clothes on as it has no ‘caring well’, in addition to the other ‘wells’ – see below, reproduced under the open government license.

dementia-well-pathway

The relentless airbrushing of ‘caring well’ might suit people who wish to pretend that social care does not exist, or that clinical specialist nurses (Admiral nurses) do not exist either, or that respite care and domiciliary care are an utter irrelevance – but sadly this rests uneasily with the rest of the world’s policy on dementia.

WHO therefore arrive at a much more balanced view of ‘dementia friendliness’, para. 31:

31. A dementia-friendly society possesses an inclusive and accessible community environment that optimizes opportunities for health, participation and security for all people, in order to ensure quality of life and dignity for people with dementia, their carers and families. Shared key aspects of dementia-friendly initiatives include safeguarding the human rights of people with dementia, tackling the stigmatization associated with dementia, promoting a greater involvement of people with dementia in society, and supporting families and carers of people with dementia. The concept of dementia-friendliness is tightly linked to societies also being age-friendly. Both age- and dementia-friendly initiatives should take into account the fact that a significant number of older people are living alone and are sometimes very isolated.”

And I feel this is one which clearly reflects a rights-based consciousness, investing in concepts such as autonomy and dignity, the themes of the Alzheimer’s Europe conference in Glasgow in 2014. This definition gets away from the “does he take sugar?” approach to dementia, and affords people with dementia and carers with hugely more respect. Now that the World Health Organisation have given a lead, there is now a definite need for England to up its game.

@dr_shibley

 

Note. Dr Shibley Rahman’s book on integrated care pathways in dementia is about to be published by Jessica Kingsley Publishers on January 19th 2017. It is called “Enhancing health and wellbeing in dementia: a person-centred integrated care approach”.

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Enhancing health and wellbeing in dementia: a person-centred integrated approach, reviews

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This is a book all about a possible integrated care pathway for dementia. It places at the heart of the narrative a person who’s received a diagnosis of dementia and the people who care for him or her, so nobody is left behind.

Thanks to the following for their pre-publication comments for my book to be published on 19 January 2017. I should like to thank all of the people below for considering the whole manuscript before offering the following responses.

The abbreviated comments are also provided on the Amazon UK page for my third book on dementia.

 

‘This important book continues our journey of what it means to see the person beyond their diagnosis of dementia, with a fresh focus on freedom, dignity and human rights. Dr Shibley challenges the idea that nothing can be done to improve dementia care. He brings practical thinking around how we can move towards truly integrated, person-centred ways of working – making a timely and valuable contribution to our collective understanding.’

– Dr Helen Sanderson, author of Person-Centred Thinking with Older People

 

“There can be no doubt that ‘Enhancing Health and Wellbeing in Dementia’ should be essential reading for anyone with an interest in improving the lives, and rights, of people living with dementia. It is an important book which is both comprehensive and practical – no easy matter to achieve! His encyclopaedic span concludes appropriately with the primacy of person-centred approaches, the importance of dignity, quality and leadership – yes, yes, yes!”

– Des Kelly OBE, Chair, The Centre for Policy on Ageing

 

 

“Shibley’s voice has emerged as an important one to take notice of within dementia care. His ability to draw together a huge range of knowledge from many different spheres of research, practice and policy and to use it to light our way rather than confuse us further is unique.”

– Prof Dawn Brooker, Director of the Association for Dementia Studies at the Worcester University, UK

 

“An absolute gem of a book. Through his career, Shibley Raman has been sequentially academic neurologist, service user, family carer and blogging activist. His learning and wisdom have been distilled into a highly readable, comprehensively referenced and bang up-to-date companion for anyone who needs to learn and understand about people with dementia and what can be done to help them, their families and professional carers to get the very best out of life.”

– Prof Robert Howard. Division of Psychiatry, University College London

 

“Practitioners, family carers and people with dementia looking for a comprehensive resource about dementia need look no further. Few books combine detailed explanations about clinical aspects of dementia with policy analysis and yet remain so centred on people’s individual experiences. This is an important resource for anyone who wants to understand more about providing better dementia support.”

– Jo Moriarty, Senior Research Fellow and Deputy Director, SCWRU, King’s College London

 

“The third of Rahman’s books on issues relating to dementia. Another must-read text that discusses the many and varied elements of what is required to enhance the lives and wellbeing of people with dementia. I particularly like his style of telling us what we can expect to learn from each section and suggestions for further reading.  This, as well as the first two books from the author, is an essential read for all health and social care students in gaining an overview of caring in dementia.”

Dr Karen Harrison Dening, Head of Research & Evaluation, Dementia UK

 

“This is a complex and difficult journey and Dr Rahman’s book is like having an informed, interested, intelligent and profoundly humane friend by your side on the journey through. This book is a friend that is encyclopaedic in knowledge and who is not afraid to have opinions and to express them. We are part-way along the journey, we have come a long way but we have far to go. This book helps us reflect on where we are and the road we have travelled, all the better to plan and travel the road ahead.”

Prof Sube Banerjee, Chair of Dementia Studies at Brighton and Sussex Medical School, co-author of the English dementia strategy (2009) “Living well with dementia”

 

“‘Great book on integrated, person-centred dementia care. Clearly identifies issues often overlooked: importance of relationships in delivering good care; pivotal role of care homes in caring for people with dementia; and value of addressing staff needs so they can be in good relationship with others. It’s not rocket science!’”

— Prof Julienne Meyer, CBE, Professor of Nursing: Care for Older People and Executive Director: My Home Life, City University London

 

“This is a wonderful book, for students, health professionals, researchers, policy makers, politicians and families, and for people who may be in the early stages of one of the diseases that causes dementia. This is a book that challenges but also gives hope. Which I think is the greatest gift of all.”

—Lisa Rodrigues, CBE, writer, coach and mental health campaigner, www.LisaSaysThis.com

 

‘Shibley Rahman’s last book in his trilogy on dementia represents a comprehensive and thought provoking tour de force through the subject matter – great reading for any health and social care professional, academic and interested lay person. Here is a perspective from an author who in himself integrates academic qualifications in medicine, law and management with a lived experience of disability. A unique read!’

— Reinhard Guss, Chair, Faculty of the Psychology of Older People, British Psychological Society

 

“What they all have in common is a need for health and social care professionals to come into their lives with understanding, and a recognition of the need for the diseases that cause dementia symptoms to be understood, so that the person or their carer never feels they are being led blindly through our health and social care systems. They don’t need us all to be experts in the scientific constructs of dementia, but they need us to know enough to respond sensitively and with confidence.

A better understanding of what person-centred care is, in the context of dementia, is what will help us to achieve this. I am hopeful that this book will  appeal to specialists and non-specialists alike, and that it will inform and influence professionals who support people living with a dementia.

This book is an important milestone in Dementia Care literature as it provides information to help us answer the difficult questions we face as professionals helping to support people and families. The different types of dementia all have in common that they cause a person to have needs around changing health and wellbeing. The discussion flowing through this book, points to where the answers are to improving how we meet those needs.”

— Lucy Frost

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Launch – Enhancing health and wellbeing in dementia: a person-centred integrated care approach

 

Thank you very much for attending my third book launch here in the Arlington Centre. The last book launch was in July 2015, which I co-hosted with Kate Swaffer and Beth Britton.

 

This third book is called ‘Enhancing health and wellbeing in dementia: a person-centred integrated care approach”, published by Jessica Kingsley Publishers on January 19th 2017. The title reflects that every person has a human right to health, and that wellbeing is a critical part of wellbeing. People are entitled to the best of care regardless of setting – for example, Dementia Care Mapping™ (DCM™ ) has been used as an observational tool which has been designed to be used within formal care settings such as care homes, nursing homes, day services and hospitals. This book is, in fact, in part dedicated to Prof Dawn Brooker. The book is also dedicated to Prof Martin Rossor, national director for dementia research, for whom I worked in 2003.

 

I should welcome to you to participate fully in the afternoon, which will be introduced by Lisa Rodrigues CBE.

 

There’s an open question for discussion at the end to which there’s no right answer. As the delegate list is a powerful mixture of persons living with dementia, carers, social workers, AHPs, managers, academics, technologists, nurses, leads, physicians, psychologists, and people who defy any sort of categorisation, to name but a few, I anticipate it will be a lively discussion. My book is intensely evidence-based but not in a way, I hope, which is off-putting to the primary audience – who are not commissioners, but persons living with dementia and carers. I certainly believe that it is the primary duty of researchers at least to think about the basic translation of research into practice. many of the interventions and service developments will ultimately rely on this.

 

Thankfully, there are people in care settings who are devoted passionately about the environment of care, for example helping carers identify, find solutions and create a care plan to overcome mealtime eating problems in dementia. ‘Working with’ collaboratively not working to patients has been a fundamental change in attitude for organising services and research, and the fundamentals of co-production are intimately linked to citizenship and human rights. And we do need to ensure people get access to the right care at the right time. For example, there can be difficulty seeing your GP, or it is inadequately acknowledged that dementia care requires strategic consideration of palliative and end of life care providers, including hospices. It is noteworthy that, through working in partnership with their local community and care providers, hospices can ensure that the best of hospice care is extended to everyone affected by a diagnosis of dementia within their local community.

 

The NHS Five Year Forward View, the current strategic ‘masterplan’ of the NHS, emphasises integration, personalisation and empowerment:

 

There is broad consensus on what the future needs to be. It is a future that empowers patients to take much more control over their own care and treatment. It is a future that dissolves the classic divide, set almost in stone since 1948, between family doctors and hospitals, between physical and mental health, between health and social care, between prevention and treatment.”

Chapter 1, Five Year Forward View, 2014 [https://www.england.nhs.uk/ourwork/futurenhs/nhs-five-year-forward-view-web-version/5yfv-ch1/]

 

Dementia has been the target of much stigma from society, and despite the rhetoric of ‘parity of esteem’, much more can be done to understand the physical and mental health needs of persons living with dementia. Recent initiatives such as ‘dementia friendly communities’ have identified that dementia is unlikely to be the only medical condition a person might live with long-term, and all that communities should be inclusive and accessible. Preventing certain people from being lonely and isolated has immeasurable social and well-being benefits for the individual. There are some amazing ‘dementia friendly’ initiatives – for example, a visit to the theatre can have a profound impact on people living with dementia and their families. It is crucial that all initiatives are culturally inclusive too, including raising awareness and promoting understanding of dementia within BME communities, which might mean physically visiting day centres, community groups and religious centres to talk about dementia and tackling the stigma that surrounds dementia.

 

Dementia is thought to be the most feared condition in adulthood, and this can affect diagnosis-seeking behaviours as well as the message that ‘nothing can be done’ after a diagnosis. A person never receives a diagnosis of dementia alone; so, understanding how the diagnosis impacts on that person and those closest to him or her is of fundamental importance. What happens after a diagnosis can be incredibly complex, and we need health and social care systems which are flexible, adaptable, and correctly resourced to cope. Interventions for living well, supporting well or caring well are not just medical, but can also be psychological (cognitive or behavioural) – and might prevent further decline. Professionals can unfortunately instil a feeling of helplessness in a person diagnosed with dementia, referred to within Kate Swaffer’s construct of ‘prescribed disengagement’™.

 

But an alternative view is possible.

 

Take for example Wendy Mitchell – living with dementia:

 

However, I’m also hoping I can convey that, although we’ve been diagnosed, people like me still have a substantial contribution to make; we still have a sense of humour; we still have feelings. I’m hoping to show the reality of trying to cope on a day-to-day basis with the ever-changing environment that dementia throws at those diagnosed with the condition. Living well with dementia is all about adapting. Adapting to new ways to enable us to live better for longer with dementia.”

 

(Wendy Mitchell’s blog – “Which me am I today?” https://whichmeamitoday.wordpress.com)

 

Dementia is a prevalent condition, but trends are complicated due to the effect of risk reduction work, the numbers of our ageing population and improved rates of diagnosis nationally. There are possibly about 900,000 people currently living in the UK with dementia. However, the nature of the condition means that managing it can pose unique and sometimes difficult issues, both in the community and in other care settings, and “dementia is everybody’s business” meaning that this is a widespread societal concern, not just the caring professions. With the right support and opportunities, people with dementia and carers can successfully communicate, engage, participate and continue to be part of relationships and communities, and this is no matter how advanced their dementia. Indeed, in the last few years there has been massive progress in communities becoming supportive to people with dementia and carers. It’s appropriate that this touches the co-design of national and local policy too.

 

This third book provides some of the ingredients to a recipe providing the change for people living with dementia and carers would be supported in a holistic, person-centred way. It is impossible to deliver person-centred care in an exceptional way, without staff feeling properly supported and empowered to fulfil their roles. The language we use is a critical aspect to this. Notwithstanding, there is a strong sense of interconnectedness in the ‘dementia’ sphere, and people in person-centred integrated care tend to be aligned to certain values of openness, trust, valuing difference, innovation and collaboration.

 

There have been enormous strides in how people living with dementia are supported, however there is always more to be done. Technology now embraces telehealth, telecare, mobile health, telemedicine, e-health, smart home technologies and Internet of Things, but is increasingly including informatics (including electronic health and care records), big data, artificial intelligence as well as health and care robotics. There’s no reason why dementia care and support in the future should be excluded from these technological developments, with the growing use of mobile devices, apps and social networks is becoming significant in enabling people to live more independent live. Together with care planning and continuity of care, the basic infrastructure of integrated care can be formed. The intelligent use of technology is transforming the way that people connect and services are delivered and gain resonance. Digital technology and social networks provide some of the most powerful tools available today for building a sense of connectedness among groups of people with similar interests and concerns.

 

Cost pressures are requiring providers to find new ways of developing a compassionate, capable and competent, yet affordable workforce. Furthermore, both specialist and generic services can struggle to cope with the increased demand upon services. We know there’s a ‘funding gap’ referred to the ‘Five Year Forward View’. But this should be the driver behind transformation plans. Many people involved in dementia care feel there’s also a ‘time gap’ – people with dementia need more of it and hospitals don’t seem to have any. The experience of someone with dementia is often affected by how well the discharge out of hospital goes. For example, a specialist occupational therapist to make sure we got the discharge process right for dementia patients and focussed on safe transfer of care from hospital into the community. Many would like to give a commitment to really making time for residents in its care homes and houses allows all to be treated as individuals, as this provides an environment where residents who are living with dementia can improve their quality of life.

 

The pressures on residential care are enormous. Some care homes face insolvency. Managing risk through correct governance is important on clinical, business and financial axes; by managing risk you can better prepare for, understand and minimise it in order to achieve care aspirations. To embrace person-centred care it is necessary to embrace an appropriate culture, and this might require strategic change management – it’s not simply a question about physical buildings, nor isolated ‘pledges’. Each person is an individual with individual needs and changes to the environment needs to nurture that person, and this includes the health and wellbeing of staff. The potential problem with framing promoting wellbeing as ‘activities’ is that the focus instead of being on the person becomes focused on the task. Promoting wellbeing might advance ‘life skills’ and improve mental condition, helping and inspiring participants to reminisce and rediscover aspects of their lives. Ideally then all ‘activities’ would be based on the interests, desires and wishes of our residents, and might include tai chi, massage, cream tea, arts, singing, flower arranging, or music. We know that communication is incredible important. Stories can strengthen emotional links between generations, and help to mitigate against negative effects of the combination of dementia, depression and loneliness in communities.

 

We live in exciting times.

PROGRAMME

 

2.00 Introduction Lisa Rodrigues CBE

2.10 Preventing excess disability through psychological approaches: a clinical psychologist’s view, Reinhard Guss

2.25 Co-production, human rights and citizenship, Alison Cameron

2.50 Technology and supporting well, Maneesh Juneja

3.10 Acute hospitals and caring well: a clinical nursing specialist’s view, Lucy Frost

 

3.30 Networking Break (with afternoon tea and biscuits)

 

3.50 Acute hospitals and caring well: a physician’s view, Avinash Sharma

4.10 Care homes and promoting wellbeing, Yvonne Manson and Joe Walker

4.30 Hospices and dying well, Sarah Russell and Marie Cooper

4.50 Living alone at home, Wendy Mitchell and Jo Moriarty

 

5.10 Open discussion

 

Question:

How can we best address the needs of persons living with #dementia and those who care for them?

 

5.30 End.

 

 

 

Dr Shibley Rahman

London, 16 November 2016

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“Walk the Walk, Talk the Talk” by Keith Oliver

‘…At one time I thought I was bullet proof: I was wrong. No one is.’

On New Year’s Eve 2010, Keith Oliver was told by a doctor that he had Alzheimer’s Disease. He was just 55, the head of a thriving primary school, a husband, father and grandfather, in the process of studying for an MA in Education.
Walk the Walk, Talk the Talk is the story of Keith’s life before, during and since receiving his diagnosis, told not just by Keith, but by the health professionals, friends and family who know him best, and including a selection of the talks he has given to a wide variety of audiences since his diagnosis. This is a story of hope and encouragement that is both moving and inspiring.

‘An essential companion for anyone who has been diagnosed with dementia, or those close to them… It’s a damn good read.’

– Richard Madeley, Alzheimer’s Society Ambassador

Join Keith Oliver for the launch of his new book
Walk the Walk, Talk the Talk

Saturday 12th November 10am-3pm

Venue: Canterbury Christ Church University, Augustine House (room AH1.21)
Refreshments will be available
Keith will be giving a short presentation about his book at 10.30am, 12pm and 2pm, but you are welcome to drop in at any point during the day for your signed copy at the special promotional price of £5.
Directions to Augustine House can be found here.

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“Care homes are care homes – and we’re determined to make a success of them”

Not all the world is in financial distress.

The good news is – McDonald’s third-quarter revenue has topped analysts’ estimates, helped by international markets like Britain and Canada, as well as the expansion of its all-day breakfast menu in the US.

When it comes to English politics, you can be pretty certain that social care will be shunted to be bottom of the pile. Occasionally, privatisation of the NHS surfaces to the top.

Integrated care is a Pandora’s box. Once you begin to look into it, you get a sense of the parts of the health and social care systems being intimately inter-connected with one another. While it might be a political priority ‘to make a success out of Brexit’, there seems to be less enthusiasm about sorting out intermediate care, GP access or delayed transfers of care/discharges.

I feel that the various models of care can get bewildering, but the idea of a ‘person-centred co-ordinated care’ definition that focuses on the individual as the organising principle for services is useful to me. I find less interesting all the minute details about the operations and processes needed to make integration work.

Care homes should indeed be what ‘it says on the tin’ – i.e. pass the Ronseal test, i.e. homes where high quality care takes place.

Becoming a care home resident is meant to be a positive choice, and not symbolic of failure by anyone. It could be a time to meet new people, and have someone help you with mealtimes, making you take your meds on time, doing your washing, for example, if you could benefit from the help.

Part of the aim of ‘opening up care homes’ was so that care homes were not adopting a prison or fortress mentality – and likewise residents aren’t to be expected to want to feel as if they’re in hospital. It’s not meant to be like living in a hôtel either – it’s your home.

Residents should be entitled to the best possible health care as part of a community of a care home as he or she could expect from being in his or her own home. But this is all part of the complicated web that has been weaved about ‘avoidable admissions’ – there clearly has been a knock on effect not just from swingeing cuts in social care, but reductions in ease of GP home visits or community nursing.

There are a number of things going wrong simultaneously, which are not just to do with the total spend on the NHS and social care (inadequate though they are). For example, we have payment systems that reward organisational activity rather than collective outcomes; regulation that focuses too heavily on organisational performance rather than system performance; and the lack of a single outcomes framework to promote joint accountability for integrated care. Promotion of wellbeing of residents in a care home, who like their genealogy tree, or like their cat v dog competitions, should be a valid outcome in itself, in the same way that staying out of hospital might be?

This evening I signed a petition that all dementia care should be free at the point of use. The rationale behind me signing this (“Frank’s Law”) is that I feel there should be no fundamental difference between your eligibility for funding streams in NHS and social care. And we know what the major issues are. The King’s Fund Barker Commission established that the case now for change, for a single point of commissioning of health and social care, is overwhelming. Given that the end point of dementia care should be examined for whether it is health or social care, which can be a somewhat arbitrary decision, it would be helpful if the collection of monies for health and social care were amalgamated at source. Promotion of private social insurance system might be political dynamite, but the discussion of social insurance systems across different jurisdictions is an important one. The care (and housing) sector are in desperate need of financial long term stability, which cannot all be left to market forces, and needs some national infrastructure State guidance.

The present day situation, however, is that commissioning is more fragmented than ever, at a time when the obligation must to integrate around the needs of an ageing population with a mixture of co-morbidities that truly defy service boundaries in a complex way. It would be easier to organise care around a group of providers who agree to take responsibility for providing all care for a given population for a defined period of time under a contractual arrangement with a commissioner. Providers are held accountable for achieving a set of pre-agreed quality outcomes within a given budget or expenditure target.

There are ways of rewiring the system better. Bundling payment for services that patients receive across a single episode of care is one way to encourage doctors, hospitals and other health care providers to work together to better coordinate care for patients, both when they are in the hospital and after they are discharged. Also, in the 2013 Spending Round, the government had announced a new pooled fund of £3.8 billion to try to encourage health and social care organisations to co-ordinate their services. This came to be called the Better Care Fund, and built on the government’s commitments in 2010 to pool some local funds for developing integrated services. Pooled budgets in some form are likely to continue to be important.

But merely bundling the payment is not enough. More needs to happen, including reductions in unnecessary care, reductions in readmissions, lower risk and complication rates for patients, and improved patient function and outcome, for example through the mapping of bundled care payments to a coherent system of valus-based commissioning.

Integrated care was not originally a major part of the coalition’s plans for NHS reform. Yet, as a result of its troubled passage from White Paper to law, Lansley’s diabolical Health and Social Care Act 2012 turbo boosted competition propping a legal framework where integration could be framed as uncompetitive. The Care Act 2014 also placed a duty on local authorities to promote the integration of care and support services with health services (and health-related services like housing) where this will benefit patients and quality of care.

There’s now a genuine concern about rushing the change. The speed of strategic change describes how fast firms are able to implement a new strategy. The resource management perspective suggests that firms need to orchestrate their resources to create new capabilities that are then used to implement strategies. But with Government borrowing still in turmoil, and limited funds to kickstart the ‘sustainability and transformation process’, the political will to drive enhancing health and wellbeing in care homes may be seriously lacking. The danger is if virtually all the money in the Sustainability and Transformation Fund is going into sustainability and deficit reduction there is not much to support transformation.

To enhance health and wellbeing in care homes, I believe in a new set of 5 Cs. Outcomes in the following could be used to produce a structured framework for promoting quality in an extended network involving hospitals, GPs and care homes in an extended network, and help to resolve the problem where commissioning is done from the perspective of the bottom line not quality of care.

(a) care planning

Care planning is a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future care. Frequent users of healthcare services are a vulnerable population, often socioeconomically disadvantaged, who can present multiple chronic conditions as well as mental health problems. Case management is a collaborative approach used in parallel with care planning to assess, plan, facilitate and coordinate care to meet patient and family health needs through communication and available resources with the intent to improve individual and health system outcomes.

(b) caring for health

There’s clearly a policy issue of who and how this will be provided, but the aim would be to deal with problems in physical health e.g. falls, fractures, infections, sensory impairment or mental health e.g. apathy, depression, of residents at the first available opportunity. This might be done through an extended GP service or some form of interface geriatrician, for example.

(c) caring for wellbeing

Wellbeing is a multi-faceted phenomenon, and could be promoted in a number of ways, e.g. gardening, arts, music, sporting memories sessions. But the trick is to focus on the person not the task; framing the narrative as “activity rounds” embues unnecessarily a biomedical twang on something which is supposed to be pleasurable and creative. “Dementia Care Mapping” will undoubtedly be invaluable tool for bridging service and research in this area.

(d) continuity of care

People tend to experience the worst care at the transitions of care. Ideally, people should have the best care wherever they are, e.g. at home, hospital, hospital or care home, and there should be smooth interoperability of key health and care information between different settings. At some point, a person might need to shift from living well with a condition to preparing for a good death with a terminal illness, and ideally everyone needs to be familiar with palliative care and end of life. Also, clearly delayed discharges and delayed transfers of care are factors which worsen social care outcomes and NHS outcomes of patient or user “experience”.

(e) care enablement

Whether through a medical intervention, social care or therapy services (physio, OT), for example, a critical feature of living with long term conditions is community based rehabilitation whereby people are given help to live life to the full. Such a package might be intensified, for example, when a person is discharged from hospital.

It’s clear that a long view is now needed.

There are many outstanding examples of care homes currently, but in universalising the best we should be aware that there are wider problems with the health and social care systems which need attention.

The care home sector itself is about to get squeezed through #Brexit and is already squeezed financially in a number of different ways, but somebody somewhere has to have the political will ‘determined to make a success of it’. A critical part to this is financial stability, staff recruitment and retention, and fostering links between caring and housing.

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Dr Shibley Rahman integrated dementia care book launch programme

Note that this event is currently fully booked – although there is a waiting list (contact @dr_shibley if interested).

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