The Golden Ticket: Primary care takes the lead in improving dementia care

The Golden Ticket is a new approach to the management of dementia in primary care, piloted by the Buxted Medical Centre in East Sussex. By working with a range of partner agencies to provide a coordinated package of support for patients and their carers within the community, the project is already showing a significant reduction in acute admissions, while also reducing reliance on GP consultations and improving patient experience.

The need for better dementia support in the community

Sussex has more people living with dementia than anywhere else in the country. However, a local clinical review of dementia services had identified significant issues with the way care was provided for dementia patients and their carers. This included fragmented access to information and support and a primary care service ill-equipped to manage slow-declining dementia, with no formal approach to care planning. These issues were resulting in poor outcomes for patients, a strain on carers, and high costs to the NHS, including a high number of acute admissions.

The Golden Ticket project is designed to address these issues, creating a more coordinated pathway of support for patients and their carers, and avoiding a focus on hospital-led care. It aims to fundamentally improve quality of life for local people affected by dementia, while also embedding the recommendations in the National Dementia Strategy and the Prime Minister’s Challenge on Dementia 2020.

Developing a multidisciplinary package of support

The project is led by Buxted Medical Practice, working closely with High Weald Lewes Haven Clinical Commissioning Group (HWLH CCG) and partner organisations in primary and secondary care, the local authority and third sector. It is funded by the Health Foundation’s Innovating for Improvement programme.

The project provides a multidisciplinary package of support including health and wellbeing interventions and community support. The model is proactive in its response to patients, providing timely access to health and social care. This includes a primary care worker, medication reviews and a weekly clinic, which intervenes quickly if an individual's condition deteriorates.  

Dementia guides, people from the charity Know Dementia, act as the main point of contact for patients and carers. They provide emotional support and practical advice while also facilitating a timely response from a range of agencies to support patients. Before the pilot, if patients got into difficulty, they were reliant on a referral to secondary care services to receive help.

Sussex Partnership NHS Foundation Trust provides secondary care services for the project, including a memory assessment service, a multidisciplinary team to review cases and a crisis team. In addition, primary care staff involved in the project can access support through a telephone helpline, provided by the trust.

Work started with a successful three-month pilot within Buxted Medical Centre, working with 37 dementia patients and their carers. Elements of the model are now being rolled out more widely and on approval of the full business case, the full model of care will be rolled out across 20 GP practices in the CCG area.

Freeing up GP consultations and reducing acute admissions

Setting up the project was a challenge for Buxted Medical Centre, as it involved developing a new integrated system to work alongside existing services, increasing staff understanding of dementia, and implementing information sharing protocols to ensure all partner organisations were kept up to date. However feedback from staff and partners involved has been overwhelmingly positive.

GPs at Buxted Medical Centre report that the new model frees up time and enables them to provide better quality patient consultations, as other professionals now share their case workload. As one GP puts it, 'Other concerns are addressed and managed well in other parts of the system. When the patient comes to us, we do what we do best.'

Kim Grosvenor, Senior Programme Manager – Dementia Transformation at HWLH CCG, says this positive experience is really helping with making the case for the full roll out of the model of care, 'There's a real appetite from GPs to implement these initiatives, as they have shown to be beneficial and cost-effective.'

A full quantitative evaluation will be published in November 2016, but early outcomes show a 20% reduction in GP consultations and a 25% decrease in acute admissions to hospital for the patients during the pilot period, compared to the three months prior.

Transforming lives for patients

A qualitative evaluation of the project, published by the CCG, demonstrated how positive the project has been for patients and their carers, with improvements in key areas including people’s quality of life and mental wellbeing. The community that has developed around the participants is also a big benefit, providing patients with a support network. According to the evaluation, a patient said: 'Lots of us are very close. I always think I am on my own, but hearing others seems to help.'

Kim describes the Golden Ticket as ‘a paradigm shift in how dementia patients are traditionally cared for, as it supports them in all aspects of their journey with dementia’.

‘Patients and carers said they previously felt isolated and that the patient experience was poor. The project has been transformational, enabling people to live more independently and providing them with a support network.'