Dr Wendy Kaiser, Deputy Head of Service Reform & Joint Commissioning, NHS Sunderland Clinical Commissioning Group

Speaking as a senior healthcare commissioner with a specialist interest in dementia, Wendy’s presentation focussed on the challenges involved in delivering integrated care and some of the solutions that were emerging. She provided examples of some of the work that had been completed in the last four years in the north east to develop person-centred care and implement the National Dementia Strategy and discussed the implications of the integration agenda for healthcare commissioners.


Wendy acknowledged that there were multiple definitions of integrated care but made the point that for people with dementia and their families, ‘it was really quite simple’. What was needed was ‘something that feels like it belongs to them and that is focussed entirely on them’. She spoke about the importance of sustaining people’s ‘sense of self’ and making sure that they had choice and control of their journey through dementia. She gave three important reasons why person-centred care mattered to healthcare commissioners:

  • Improving choice and control enabled people to stay well and maintain their independence for longer
  • Providing practical and emotional support to carers delayed admissions to residential or institutional care
  • Effective healthcare averts attendances at Accident and Emergency departments and emergency hospital admissions which often lead to ‘step changes’ in dependency.

Traditional ways of working often fail to deliver this and so we have to work differently in future. Wendy cited work by the King’s Fund at national level to gather evidence about ‘what works’ locally in the development of integrated care for people with long-term conditions. She referenced their ‘house of care model’ and described the different elements comprising the foundations, supporting walls and protective roof, as well as the factors that lay at the heart of the house of care. She provided examples of how this model could be adapted to meet the needs of people with dementia and their families.

Wendy stressed the importance of strong foundations through effective commissioning in the house of care approach. The need to ensure that walls of the house were supported by effective joint working and communication and the overarching ‘roof’ meant that we had to move towards 7-day services with shared access to information and records and shared assessment tools and performance metrics.
Examples of work in progress included the use of community assets to improve access to care and support, such as the Healthwatch programme in Newcastle. Healthwatch trained local people to become health trainers who could then provide a range of resources and support to people living with long-term conditions. In Sunderland they have invested in dementia awareness training for their network of community health champions. These community champions can then make early referrals in to diagnostic services for people experiencing memory problems.

Interpersonal relationships are another key element of the house of care model. That is, ensuring that staff relate effectively to the people that they care for and give parity to mental and physical health needs. Staff needed to work effectively together in multi-disciplinary teams to overcome traditional organisational silos. This requires attention to: shared care management, giving equal value to the contribution of every member of the integrated care team, and providing access to specialist support on mental health issues where required. Wendy cited the work of Northumberland, Tyne & Wear NHS Foundation Trust to provide community teams with telephone access to specialist advice on mental health needs that arise during the course of their work. This has been shown to improve the quality of care provided.
An essential requirement, but also a significant challenge for integrated care, is the development of shared information and assessment systems. This includes sharing information about local needs as well as shared assessment mechanisms, joint care plans and shared performance metrics.

The role of extra care housing

Wendy went on to talk about the role of extra-care housing in dementia care pathways and a pilot programme in Sunderland to introduce ‘enhanced care’ into residential and nursing homes and a large extra-care scheme. This model involves enhanced primary care input from GPs and District nurses to offer a proactive and preventative approach to healthcare, including medication reviews and health-screening. The pilot has revealed a high level of hospital admissions amongst extra-care residents - out of 37 people assessed, 31 had experienced at least one hospital admission in the previous 12 months. As a result of the pilot new interventions included: changing the models of domiciliary care to become more person-centre, making improvements to lighting, flooring and the internal and external environment, improving falls-prevention training for care staff, and reviewing medication regularly.


Wendy stressed the importance of the housing sector rising to the challenge of supporting people with dementia to live in extra-care housing or their homes for as long as possible. There was also a need to provide adequate support with the transition where people needed to move to other accommodation. There were particular challenges with end of life care. Sunderland was working hard to implement the ‘Deciding Right’ strategy for people with dementia to enable them to prepare advance care plans while they still had the capacity to do so. There was also a challenge to support carers and front-line staff who sometimes found it difficult to implement advance care directives to avoid hospital admission when faced with the responsibility of caring for someone who was in the last stages of their life, especially out of hours when support services were limited. Wendy highlighted some of the ways that housing providers could actively promote personalised care and support including:

  • Commissioning and providing meaningful activities to promote a ‘sense of self’ and community connectedness, including investing in art-therapy through the Equal Arts programme. Sunderland CCG was considering a consortium bid from the third sector for funding for community activities for people with dementia
  • Training frontline staff in dementia awareness and working with healthcare commissioners to integrate housing assessments into referrals to early diagnostic services so that people received the appropriate type of help and support with memory loss. Wendy reminded delegates that not all memory loss was due to dementia and early diagnosis was crucial in enabling people to access appropriate help and support.
  • Investing in age-friendly and dementia-friendly environments both inside and outside the home, ensuring that homes were warm, safe and suitably adapted where possible and offering appropriate alternatives. Wendy drew attention to the importance of good lighting, access to green space and meaningful outdoor activities and friendships as well as interior aids and adaptations.
  • Housing providers were well-placed to act as care coordinators, bring health and social care agencies together for residents with complex or high levels of support need. They could support people with their diet and medication, request healthcare reviews, make environmental improvements and keep people socially connected and act as an early warning system if there was cause for concern.
The Better Care Fund 2014/15

The final part of Wendy’s presentation focussed on the potential for the Better Care Fund (BCF) to support service integration. She explained that the fund aimed to promote joint commissioning and to use existing resources more intelligently to transform care. The BCF brought together different strands of existing health and social care budgets to form a joint funding pot. Key performance indicators for the BCF were still being agreed but were likely to include:

  • A reduction in delayed transfers of care from hospital to home
  • Improvements to unplanned emergency admissions
  • A reduction in unplanned readmissions
  • Improved performance from reablement services
  • A fall in admissions to residential and nursing home care
  • Feedback from service users and carers on their experiences of the care system

The aspiration was to move towards 7-day services, with better coordinated care using the individual’s NHS number as the shared identifier on all case records, joint assessments and care planning, and shared ownership of the outcomes.