Dementia Memory Assessment Service (MAS) Audit 2019 Aim • To share the learning and best practice from the South East (KSS) MAS Audit 2019 • To facilitate networking and enable attendees to talk to others about how they are working to reduce variation within in their services • To discuss future steps for improvement

2 | Background

• 2 KSS MAS services were visited in 2018 to help process map and streamline their services. • We held a workshop on 25th April 2019, process mapping their current pathways. The London CN were able to share the learnings of their previous audits. • Purpose: learn from sharing best practice from London audits, identify variation, improve care for patients, address challenges regionally. • Result of the audit workshop, each STP/ICS held senior clinical meetings with their MH trust to help implement some of the learnings. • 23 MAS services were asked to complete an audit of 50 consecutive patients starting from the 1st January 2019. This data has been analysed at a regional level and also has been sent to London for national analysis.

3 | Methodology 2019 MAS Audit methodology • 14 organisational questions • 6 demographic questions • 50 consecutively seen patients from 1st January 2019 • 23 services participated - covering the 19 CCGs of KSS (and some patients from Surrey Heath & Farnham NE Hants) • 1150 patients in total • Females: Sussex 60%, Surrey 55%, Kent 60%.

5 | Participation List

Kent (11 services) Surrey (6 services) Sussex (6 services) Ashford East Surrey Brighton and Hove Canterbury and Coastal Farnham and NE Hants Coastal West Sussex - Northern Dartford, Gravesham and Swanley Guildford Coastal West Sussex - Western Dover Mid Surrey Coastal West Sussex - Southern Maidstone NW Surrey East Sussex Medway Surrey Heath HWLH Sevenoaks Shepway Swale Thanet Tunbridge Wells 6 | Learnings from the 2019 Audit process • First KSS MAS audit. • Kent Audit sample - interpretation of the cohort needed further clarification. Variation in organisation policy e.g. 2017 patients. • Face to face visits to each service was not possible. • Timing - summer holidays led to delay in submission of analysis • Clarity of questions i.e. more options vs clarity of them • Data not readily available through IT systems (manual extraction) – time consuming • Clinical knowledge of person undertaking the audit

7 | Analytical Limitations • Size of sample restricts definitive conclusions • Population weighting not taken into account • Data cleansing was required as services had not previously participated

8 | Highlights from Organisational questions

Question Kent (11 services) Surrey (6 services) Sussex (6 services) MSNAP Accreditation 10/11 5/6 4/6 Organisation All secondary care All secondary care 2/6 community services Primary/Secondary MAS provider 4/6 secondary care ECG prior to ACEI 10/11 all patients 6/6 Other 5/6 only bradycardia Ability to refer for CSF 10/11 Yes 6/6 Yes 2/6 Yes examination Joint working with 10/11 Yes 0/6 Yes (all ‘adhoc advice’) 0/6 Yes (all ‘adhoc advice’) neurology Joint working with 10/11 Yes 0/6 Yes (all ‘adhoc advice’) 0/6 Yes (3 ‘no’, 3 ‘adhoc neuroradiology advice’) Joint working with geriatrics 10/11 Yes 0/6 Yes (all ‘adhoc advice’) 0/6 Yes (all ‘adhoc advice’)

9 | Demographics Patients under 65 years

20% • K&M 9% 18% • Surrey 4% 16%

14% • Sussex 7%

12%

10% Young onset dementia clinical

8% lead:

6% • K&M 10/11

4% • Surrey 6/6

2% • Sussex 2/6

0% J I D A C K B F G H E O L P M Q N S R T U V X K & M Surrey Sussex

K & M Surrey Sussex STP/ICS Numerator: Total number of patients with a recorded age less than 65 11 | Denominator: Total number of patients Ethnicity

100% • Several services where 90% ethnicity was stated were

80% 100% white.

70% • Service V could not provide us with ethnicity 60% for their patients, and may

50% want to look at their system to ensure they can 40% record this in future.

30% • Other services also had a large number of patients 20% where ethnicity was not 10% stated.

0% I J D K C H F E G A B M Q N O L P T R U S X V K & M Surrey Sussex White Non-white British or non-white Irish or non- white other background Ethnicity not stated All patients

12 | % of patients recorded as living alone

• K&M 31%, 60% • Surrey 30% 50% • Sussex 40% 40% • Service K reported that 10% of patients 30% live alone, but 20% answered ‘not clear from notes’ for 22% 10% of the cohort.

0% J I F H D E G B A C K M N L O P Q T V R X U S Numerator: Total number of patients who K & M Surrey Sussex were recorded as living alone K & M Surrey Sussex STP/ICS Denominator: Total number where there was a recorded response to living alone

13 | Alcohol consumption not documented • K&M 40%

100% • Surrey 19%

90% • Sussex 10%

80% • Better documentation

70% • K&M on average recorded that 40% of patients drank more than 60% 14 units a week, Sussex 7% & 50% Surrey 6%

40% • Not enough data to investigate links with ARBI 30% • We have noted feedback that 20% there should be more granular 10% options over 14 units.

0% Numerator: Total number of patients I J H D F A E G K C B L Q P O N M T V X S R U where alcohol consumption was not K & M Surrey Sussex documented K & M Surrey Sussex STP/ICS Denominator: Total number of patients

14 | Patient history documented

Question Kent (11 services) Surrey (6 services) Sussex (6 services) • Better Smoking 67% 90% 94% documentation

Hearing 52% 32% 36%

Vision 51% 70% 81%

Falls 63% 76% 93%

15 | Pathways % of referrals referred from GP

• Majority of patients referred 100% by GPs 90% • Surrey 80%

70% • 4% from acute hospital

60% • Services N & M, 12%

50% from acute hospital 40% • Remainder of referrals were 30% mostly called ‘other’ 20%

10%

0% J I C E F H K A G B D L O Q P N M S X U V T R Numerator: Total number of patients who K & M Surrey Sussex were recorded as referred from the GP

K & M Surrey Sussex STP/ICS Denominator: Total number where referral origin was recorded

17 | Waiting times from referral to initial assessment

• K&M 5 weeks 25 • Surrey 6 weeks • Sussex 14 weeks 20 • In Sussex there is a range from 6 weeks to 22 weeks. 15 • Correlation between when

10 scan requested and waiting times

5 Those with both referral and initial assessment date where referral was before the initial 0 assessment (excluding data quality issues) J I A H C E G D K B F O M N P L Q X U V T R S K & M Surrey Sussex K & M Surrey Sussex STP/ICS 18 | % who had an initial assessment in 6 weeks from referral

100% • K&M 88%

90% • Surrey 60%

80% • Sussex 21%

70% • Service ‘J’ - 100% in 6 weeks 60%

50% • Service ‘U’ 0%

40%

30%

20% Those with both referral and initial assessment 10% date where referral was before the initial assessment (excluding data quality issues) 0% J I F K G B A D H E C Q L P M N O S R T V X U K & M Surrey Sussex 19 | K & M Surrey Sussex STP/ICS % of patients whose initial assessment was in clinic

• K&M 72% 100% • Surrey 75% 90% • Sussex 82% 80%

70% • Variation across KSS from 100% to 42% 60%

50%

40%

30%

20% Numerator: Of those with a recorded 10% response how many were seen in clinic 0% Denominator: all patients excluding J I E F B C K A D H G Q O P M L N U X V R T S blanks K & M Surrey Sussex K & M Surrey Sussex STP/ICS 20 | Scanning Scanning

Question Kent (11 services) Surrey (6 services) Sussex (6 services) CT/MRI reported by 11/11 6/6 4/6 neuroradiologists View scan images (e.g. 10/11 4/6 2/6 using PACS) Appointment facilitated 10/11 0/6 4/6 by MAS service Refer for PET scans 10/11 6/6 3/6 Refer for DAT scans 11/11 6/6 4/6

• Some services noted that it would have been useful to be able to indicate further types of scan e.g. SPECT, DSQUID etc. • Surrey do not facilitate any appointments. Is this necessary?

22 | Mean scan wait

• K&M 5 weeks

9 • Surrey 2 weeks

8 • Sussex 5 weeks

7 • ‘L’ has 1 week 6 • ? time of scan related to

5 assessment/request

4

3

2 This is calculated using the date scan was 1 requested to the date the scan was

0 performed (Excluding data quality issues - J I H F A G K E B C D Q O P M N L V X T U S R where this could not be worked out. K&M K & M Surrey Sussex 25%, Surrey 2%, Sussex 28%) K & M Surrey Sussex STP/ICS 23 | % of documented scans who had MRI/ CT/ Both 100%

90% • Variation 80% • ‘B’ has 80% MRI 70% • ‘V’ and ‘X’ have 94% 60% CT

50% • CT & MRI both required is about 6% 40% in ‘B’.

30%

20%

10%

0% I J B A D F H K E G C Q O L N P M S R T U V X This graph excludes those who have not K & M Surrey Sussex had a scan and those who have not had a overall % MRI overall % CT overall % MRI and CT of documented, not having a scan scan type documented.

24 | Reasons no scan was completed

% contraindicated % previous scan

5% 50% 4% 40% Range 3% 30% • Contraindicated: 0-4% 2% 20% 1% 10% • Previous scan: 0-44% 0% 0% I J C K A B E H L P R V • Refuse scan: 0-14% A C E G M N Q X S U O N Surrey Sussex • Not required 0-42%

% refuse scan % not required

16% 45% 14% 40% 12% 35% 30% 10% 25% 8% 20% Numerator: each reason that no scan was 6% 15% completed e.g. previous scan 4% 10% 2% 5% Denominator: all patients 0% 0% I C A B E I N O L P R S V H K A D G M O N Q V S K & M Sussex 25 | % performed specialist investigation

• PET/DAT/CSF 12% • Variation 0-10%

10% • Certain services do not seem to perform 8% specialist investigations 6%

4%

2%

0% J E F I C L P S T H D A B G K M Q O N R U V X Numerator: patients where specialist K & M Surrey Sussex K & M Surrey Sussex STP/ICS investigation was performed Denominator: Patients with a recorded response to the question whether a specialist investigation was performed 26 | (Excludes blanks) Diagnosis Diagnosis

Ave wait weeks from ref to diag 35

30 25 • With/without scan 20 • Range 9 to 32 weeks 15

10

5

0 J I H K D F G E A C B P O Q N M L X T U S V R K & M Surrey Sussex Ave wait ref to diagnosis had a scan Ave wait ref to diagnosis did not have a scan

% diag in 6 weeks 40% • K&M 5% 35% 30% • Surrey 27% 25% • Sussex 5% 20% 15% 10% 5% Those with both referral and diagnosis 0% assessment date where referral was before the I J C F G A K B E D H Q L M P N O R V T S U X initial assessment (excluding data quality K & M Surrey Sussex 28 | K & M Surrey Sussex STP/ICS issues) Average wait from assessment to diagnosis • K&M 23 weeks 35 • Surrey 5 weeks 30 • Sussex 9 weeks 25

20

15

10

5 Those with both initial assessment date and diagnosis date where 0 diagnosis date was before the initial I J H F K B D G E C A P Q O N L M S T X R V U assessment (excluding data quality K & M Surrey Sussex issues, Kent 13% could not be calculated, Surrey 1%, Sussex 2%) K & M Surrey Sussex STP/ICS

29 | Diagnoses

100% 90% • Some services have high % 80% of dementia diagnosis i.e. 70% service ‘E’ and ‘N’

60%

50%

40%

30%

20%

10%

0% I J L E A K F H D G C B N M P O Q R V X T S U Numerator: Recorded diagnosis K & M Surrey Sussex % dementia % MCI % Other Denominator: All patients

30 | Diagnoses with dementia breakdown

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0% F A C I H E K & M B K G J D N M L Surrey P Q O X R V Sussex S U T

% sub AD % sub vas % sub mixed % sub unspec % sub Lewy bodies % sub frontotemporal % sub Parkinson % sub alcohol related dementia % No dementia 31 | Dementia diagnosis breakdown - chart form Subtype K&M Av (range) Surrey Av (Range) Sussex Av (Range) Alzheimer's 24% (10% - 48%) 38% (28% - 54%) 32% (14% - 54%) Vascular 13% (4% - 20%) 10% (8% - 14%) 7% (2% - 28%) Mixed 29% (14% - 50%) 14% (4%-22%) 17% (6% - 32%) Unspecified 3% (0% - 6%) 3% (0% -6%) 3% (0% - 4%) Lewy Bodies 2% (0% - 8%) 3% (0%-8%) 2% (0% - 6%) Frontotemporal 3% (0% - 6%) 1% (0% - 4%) 0% (0% - 2%) Parkinson's 3% (0% - 6%) 2% (0% - 2%) 1% (0% - 4%) Alcohol related 1% (0% - 8%) 0% (0% - 2%) 0% (0%) Not dementia 26% (12% - 42%) 30% (6% - 42%) 37% (22% - 66%)

32 | Patients with a diagnosis of dementia questions

33 | Referred for CST

100%

90%

80% • CST not available

70% • Providers with ‘Not falling in these 60% categories’ did not 50% answer the questions 40% about CST

30%

20%

10% Numerator: responses to question referred for CST 0% I J H D E B F K G A C M Q O P L N U R T S V X K & M Surrey Sussex Denominator: those with a CST, % offered (yes or declined) CST, % no not app dementia diagnosis CST, % no service not avalible CST, % not falling in these categories

34 | Offered care co-ordination/navigation

100%

90%

80% • Providers with ‘Not 70% falling in these

60% categories’ did not answer the 50% questions offered 40% care.

30%

20% Numerator: responses to 10% question offered care co- ordination/navigation 0% F G I K E K & M A C H D J B Q M P Surrey N O L S V X Sussex T U R Denominator: those with a dementia diagnosis Coord, % offered (yes or declined) Coord, % no not app Coord, % service not avalible Coord, % not falling in these categories 35 | Offered psycho-education course

100%

90%

80% • Providers with ‘Not 70% falling in these

60% categories’ did not answer the questions 50% about education 40% course

30% • Psychoeducation - START/CRISP courses 20%

10% Numerator: responses to 0% question offered psycho- H E F D B A K & M I G K J C O M Surrey L P N Q U S R T Sussex V X education course Carers edu, % offered (yes or declined) Carers edu, % no not app Denominator: those with a Carers edu, % no service not avalible Carers edu, % not falling in these categories dementia diagnosis

36 | Consent taken to be contacted for research

100%

90%

80% • Variation in take up • Not everyone asking 70% • ‘Not falling in these 60% categories includes ‘no 50% discussion

40% documented’ and ‘not appropriate’ 30%

20% Numerator: responses to 10% question consent taken to be

0% contacted for research J I B K A C D G H E F O L P M Q N T R U S X V Denominator: those with a K & M Surrey Sussex dementia diagnosis Research, dem of offered % accepted Research, dem of offered % declined 37 | Research, % not falling in these categories Was medication offered?

100%

90%

80% • Providers with ‘Not

70% falling in these categories’ did not 60% answer the 50% questions about

40% medication offered

30%

20%

10% Numerator: medication offered

0% J I B E K G D H C F A M P O Q N L U V R X T S K & M Surrey Sussex Denominator: those with a Meds, % offered (AD, DLB, PDD, Mixed) Meds, % not app (AD, DLB, PDD, Mixed) dementia diagnosis Meds, % contra (AD, DLB, PDD, Mixed) Meds, % not falling in these categories (AD, DLB, PDD, Mixed)

38 | Which medication was prescribed to dementia patients?

100%

90%

80% • A few non-

70% dementia patients

60% in K&M have been prescribed 50% Donepezil, 40% Rivastigmine, 30% Memantine and

20% Galantamine.

10%

0% Numerator: which type of J B G I D H K & M E F C A K Q M L Surrey P N O X U S Sussex V R T medication

Meds, of CEIs % Donepizil Meds, of CEIs % Memantine Denominator: those who were Meds, of CEIs % Rivastigmine Meds, of CEIs % Galantamine offered CEIs

39 | Themes from the Audit • Waiting times from referral to initial assessment • Considerable variation of initial clinic assessment versus home visit • Facilitation of scanning appointment necessary? • Why are some patients having both MRI/CT scans? • Range of 9 to 32 weeks with/without scan

40 |