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Ambition

GP has regular (at least 3 monthly) multidisciplinary case review meetings where all patients on the palliative care register are discussed.

You are involved in regular reviews with your doctor and other health and care staff, that enable you to ask for more support and adapt the support that you have to your changing needs.
 
For extra information, evidence and best practice please scroll down to the bottom of the page.

Regional offerings

GP Excellence in Greater Manchester

We are the Greater Manchester Health and Social Care Partnership's GP excellence programme.
Weblinks:
Quality Improvement toolkits: https://gpexcellencegm.org.uk/resources/quality-improvement-toolkits-gp-one/
GP Excellence website for Greater Manchester: https://gpexcellencegm.org.uk/

National offerings

NHS Continuing Health Care

NHS continuing healthcare is for adults. Children and young people may receive a "continuing care package" if they have needs arising from disability, accident or illness that cannot be met by existing universal or specialist services alone.
The process involved in NHS continuing healthcare assessments can be complex. An organisation called Beacon gives free independent advice on NHS continuing healthcare.
Telephone: Beacon free helpline 0345 548 0300
Weblink: https://www.nhs.uk/conditions/social-care-and-support-guide/money-work-and-benefits/nhs-continuing-healthcare/

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

Social Care Institute for Clinical Excellence - End of Life Care Resources

When a person is living with advanced stages of dementia, all areas of human ability are severely compromised. They have to rely on others for social engagement, occupation and activities of daily living. This section looks at what it's like to live with advanced dementia, communication and the impact on carers.
Weblinks:
Carers’ needs - End-of-life care and dementia: https://www.scie.org.uk/dementia/advanced-dementia-and-end-of-life-care/advanced-dementia/
Advanced Dementia: https://www.scie.org.uk/dementia/advanced-dementia-and-end-of-life-care/end-of-life-care/last-days-hours.asp
End of life care - dying at home: https://www.scie.org.uk/socialcaretv/video-player.asp?v=dyingathome

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

Integrated POS (IPOS) for Dementia and Translations

IPOS-Dem is a proxy-completed measure for people with dementia living in care homes. It is derived from IPOS, and developed for use by unqualified care staff working in care home settings. IPOS-Dem is designed to support systematic assessment of care home residents with dementia and incorporates common symptoms and problems experienced by this population. It is accompanied by an instruction manual on its use to support routine assessment of residents with dementia.

Website: https://pos-pal.org/maix/ipos-dem.php


Evidence


Palliative Care Guidelines In Dementia: "The inclusion of patients with a dementia diagnosis within Primary Care-led palliative care meetings can facilitate a more holistic and coordinated approach to care during the last 6- 12months of life. Having proactive discussions as a multi-professional team when someone with dementia is thought to be nearing the last few months of life will enable the early recognition of advance care planning processes that have already taken place, thereby assisting the proactive management of care in accordance with an individual’s previously expressed wishes."

NICE, End of life care for adults: service delivery:

"Develop systems enabling adults approaching the end of their life to have:

  • regular discussions with a member of their care team about changes in their health and social care needs and preferences
  • repeat assessments of their holistic needs and reviews of their advance care plan when needed, for example at key transition points, such as at discharge from hospital or when the goals of treatment have changed. "

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