Priority

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Required

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Ambition

The dementia care plan is available digitally to professionals involved in support.

If you have created a care plan with one service or team you can discuss issues in the care plan with others. For example, your GP is able to digitally access and read a care plan plan drawn up with a dementia advisor. After discussing the issue you GP can then update the care plan and makes it digitally available to the dementia advisor. You should never need to explain or bring your care plan to other services.
 
For extra information, evidence and best practice please scroll down to the bottom of the page.

Regional offerings

Dementia Wellbeing Plan for Greater Manchester; Dementia United

The Greater Manchester dementia wellbeing plan promotes personalised planning conversations with people living with dementia and carers about their needs and wants. The plan ensures an improved standard of care planning for people living with dementia and also facilitates sharing across the system. It will be available as a standardised plan which can be accessed and shared digitally between practitioners; as well as being available from the website for people affected by dementia to be using when having person centred care plan reviews
Weblink: https://dementia-united.org.uk/dementia-wellbeing-plan/

National offerings

NHS England Dementia

Dementia is a key priority for both NHS England and the Government. NHS England's work includes:
  • Developing an access and waiting time standard for dementia, so people with dementia have equal access to diagnosis as for other conditions; setting the national average for an initial assessment
  • Achieving and maintaining the dementia diagnosis rate. NHS England agreed a national ambition for diagnosis rates that two thirds of the estimated number of people with dementia in England should have a diagnosis with appropriate post-diagnostic support
  • Post diagnostic care and support; as there has been substantial progress on diagnosis, NHS England will focus on improving post-diagnostic support
Other organisations and sectors are crucial to helping NHS England deliver improvements to services for those with dementia and their carers. NHS England are working in collaboration with: Alzheimer’s Society, Public Health England, Department of Health, ADASS, Care UK, clinical commissioning groups, GP practices, Royal College of General Practitioners, Royal College of Psychiatrists, amongst other stakeholders to develop NHS England’s five year transformation plan for people with dementia.
NHS England have developed a Dementia Well Pathway which outlines standards across all aspects of the Pathway from prevention, diagnosing, supporting, living and dying well.
Weblinks:
The NHS England dementia-well-pathway can be accessed here: https://www.england.nhs.uk/mentalhealth/wp-content/uploads/sites/29/2016/03/dementia-well-pathway.pdf
You can access the NHS England dementia programme of work here: https://www.england.nhs.uk/mental-health/dementia/

NICE Dementia Guidance

This guideline brings together all the research and evidence which covers assessment, diagnosis, treatment and support. It is for people at risk of developing dementia, people who are referred for assessment, people living with dementia as well as being for family and friends and health and social care staff and commissioners. It aims to improve care by making recommendations on standards people should expect to receive from their assessment, care and support as well as on training.
Weblinks:
We have provided links to the NICE guideline for dementia and a further link is provided to guidance on how to delay or prevent the onset of dementia.
National Institute for Health and Clinical Excellence (NICE) NG16 (2015) Dementia, disability and frailty in later life – mid-life approaches to delay or prevent onset: https://www.nice.org.uk/guidance/ng16
National Institute for Health and Clinical Excellence (NICE) (2019) Dementia: assessment, management and support for people living with dementia and their carers: https://www.nice.org.uk/guidance/ng97

Personalised Care in the NHS

Personalised care is based on ‘what matters’ to people and their individual strengths and need.
Weblinks:
https://www.england.nhs.uk/personalisedcare/
https://www.england.nhs.uk/wp-content/uploads/2019/02/comprehensive-model-of-personalised-care.pdf

Think Local Act Personal (TLAP)

TLAP are a national partnership of more than 50 organisations committed to transforming health and care through personalisation and community-based support. Personalised care and support planning (PCSP) is a systematic process based around 'better conversations' between the person and their health and social care practitioners. The overall aim is to identify what is most important to each person for them to achieve a good life and ensure that the support they receive is designed and coordinated around their desired outcomes.
Weblink: https://www.thinklocalactpersonal.org.uk/personalised-care-and-support-planning-tool/What-is-personalised-care-and-support-planning/

Young Dementia UK

Support for young onset dementia (under 65); providing relevant information and also shares individual stories. This is also part of Dementia UK.
Telephone: Dementia UK Telephone: 0800 88 6678
Email: direct@dementiauk.org
Weblink: https://www.dementiauk.org/about-dementia/young-onset-dementia/

Healthwatch

Healthwatch is your health and social care champion. If you use GPs and hospitals, dentists, pharmacies, care homes or other support services, we want to hear about your experiences. As an independent statutory body, we have the power to make sure NHS leaders and other decision makers listen to your feedback and improve standards of care. Last year we helped nearly a million people like you to have your say and get the information and advice you need.
Telephone: Call: 03000 683 000 between the hours of 08:30 – 17:30 Monday to Friday
Email: enquiries@healthwatch.co.uk
Weblink: https://www.healthwatch.co.uk/your-local-healthwatch/list

Evidence


NHS England (2017) Dementia: Good Personalised Care and Support Planning: "Each person has a personalised care and support plan which records what matters to them, their outcomes and how they will be achieved - in a digital format where possible."

NHS England 2019. Universal personalised care: "Each person has a single summary care and support plan in a digital format where possible, which can be edited by the person."

Research paper, Digital technologies to support people living with dementia in the care home setting to engage in meaningful occupations, protocol for a scoping review: "People living with all stages of dementia should have the opportunity to participate in meaningful occupations. For those living in care homes, this may not always occur and residents may spend significant parts of the day unengaged, especially those living with more advanced dementia. Digital technologies are increasingly being used in health care and could provide opportunities for people living with dementia (PLWD) in care homes to engage in meaningful occupations and support care staff to provide these activities."

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