Delivering NHS and Social Care Mental Health Integration in Practice

What was the issue you were addressing or working on?

Anticipated increase in demand related to predicted rise in dementia for people aged over 75.  The CHCP already had well-established services for adults with dementia across health, social care, independent and third sectors.  However within the framework of local and national demands, we needed to explore more dynamic models of delivery.  Partners agreed that there was a need to increase access to the full range of services in a planned and consistent way.


What you did?

Integrated services for people with dementia and their carers have been developed across West Dunbartonshire Community Health and Care Partnership (CHCP) in partnership with the third sector

Service mapping and engagement was undertaken with service users, families, carers and staff.  The redesign implemented delivers increased capacity for early diagnosis, post diagnostic support and psychological interventions.  We put aside traditional models of service provision, focusing on meeting the future demands on service and the skills required within an integrated workforce. Having integrated staff within the day hospital with the Adult Community Mental Health Team, we provide more assessments, diagnosis and treatments within a person’s own home.

The integrated staff team support person centred assessments and interventions for people with dementia.  In addition to delivering local therapeutic groups within the local community and Day Care Services, we also deliver social, therapeutic and recreational activities (e.g. a Dementia café for service users).  These provide crucial community peer support for carers.  On-going carer engagement is maintained through work with Alzheimer Scotland.


What were the outcomes - benefits or otherwise?

By integrating the teams, we serve more patients, provide greater carer support and promote multi-disciplinary staff development and training. This has created a future proof model to tackle the projected demand and gives us increased capacity for assessment, diagnosis and treatment at home. Achievements include;

  • Early assessment and intervention thus preventing unnecessary admissions to hospital.
  • Facilitated early discharge from hospital and on-going intensive support in the community.
  • Improved access to home assessments and interventions provided from the multi-agency multi-disciplinary team.
  • Supporting carers to continue their caring role for longer.
  • Improved communication and joint working between health, social care and third sector staff working within the community.
  • Improved access to non-pharmacological interventions such as Cognitive Skills Training.
  • Sign-posting service users and their families to other resources.
  • Service users and their families are enabled to make the right choices for themselves about how they want to be supported and plan for the future.
  • GPs report an increased awareness of early symptoms; resulting in improving diagnosis rates, inclusion on the dementia register and positive signposting to services.
  • Provision of a warm, welcoming environment which encourages a fuller life, laughter, fun and support to be seen and heard.
  • All staff and practitioners have had the opportunity to develop and learn new skills.

Contacts - to find out more

John Russell, Head of Mental Health, Learning Disability and Addiction Services – West Dunbartonshire Community Health & Care Partnership. 01389 737764 John.russell@ggc.scot.nhs.uk