Editorial

www.thelancet.com/neurology Vol 13 December 2014 1161

For Cracks in the pathway see http://www.cqc.org.uk/content/cracks-pathway

For guidance on good dementia care see http://www.alz.org/professionals_and_researchers_dementia_care_practice_recommendations.asp

For more on the Prime Minister’s Dementia Challenge see http://dementiachallenge.dh.gov.uk/

For more on pain assessment in dementia see Review page 1216

For more on dementia as a public health priority see http://www.who.int/mental_health/publications/dementia_report_2012/

Raising standards in dementia careA review by England’s Care Quality Commission (CQC) has found unacceptable variability in the quality of care provided to people with dementia in care homes and hospitals. The CQC’s report, Cracks in the pathway, serves as a stark reminder that action to treat and prevent dementia must go hand in hand with eff orts to improve care for patients.

In 129 care homes and 20 hospitals across England, the CQC—the independent regulator of health and social care—looked at how people’s care needs were assessed, how care was planned and delivered, how providers worked together, and how quality of care was monitored. Despite the wealth of guidance available to support good dementia care, the CQC found examples of variable or poor care across more than 90% of care homes and hospitals inspected. In 34% of care homes and 42% of hospitals, for instance, the regulator found aspects of variable or poor care regarding people’s physical and mental health, and emotional and social needs.

The fi ndings of the review relate to the objectives of the National Dementia Strategy for England, published in 2009, which set new standards for dementia care. The main commitments set out in the Prime Minister’s Dementia Challenge, launched in 2012 to build on the National Dementia Strategy, were “driving improvements in health and care”, “creating dementia-friendly communities”, and “improving research”. Progress is urgently needed at every step of the care pathway: timely diagnosis and post-diagnosis support for people with dementia; information and support for families and carers; high-quality care tailored to the changing needs of patients at home and in care homes and hospitals; and excellence in end-of-life care.

In response to its fi ndings, the CQC plans to train its inspectors to understand what good dementia care looks like, to include an assessment of the quality of dementia care in future hospital reports, and to appoint a national specialist adviser for dementia care. By identifying shortcomings in the provision of dementia care, the report could help to fuel further action to raise standards of health and social care in England and elsewhere.

The development of national policies that promote the use of specifi c evidence-based approaches to care, with eff ective monitoring of the quality of care, is one way to improve dementia services, but much more is

needed. Investment in staffi ng levels, staff training, and continuous professional and vocational development will be key to building a skilled workforce that can recognise the symptoms and respond to the care needs associated with diff erent types of dementia. More integrated models of health and social care should be developed in which information about patients’ care needs is shared as they move from home to hospital or between providers. In hospitals, consideration should be given not only to the physical needs of patients, but also to their mental health, emotional, and social needs. Many important aspects of care, such as the assessment and management of pain in people with dementia, will depend on a strong evidence base, and existing guidance should be reviewed and refi ned as that body of evidence grows.

Although the CQC found many examples of good care, in 33% of care homes and 61% of hospitals, patients or their families were not adequately involved in decisions about their care. People living with dementia should be involved not only in planning their own care at a stage when they can have meaningful input into future decisions, but also in developing the policies and services that aff ect all patients.

Alzheimer’s Disease International estimates that more than 44 million people worldwide were living with dementia in 2013, most of those with Alzheimer’s disease, and that the number will rise to over 75 million in 2030. National plans to tackle dementia are needed in all regions, with a commitment from all stakeholders to make dementia a public health priority and to develop cost eff ective, culturally acceptable dementia care with appropriate support for caregivers. Community education to increase public and professional awareness and understanding of dementia could help to lower dementia risk and to reduce stigmatisation and barriers to diagnosis and care in many regions.

At the G8 dementia summit in December, 2013, participating countries set an ambition to identify a cure or a disease-modifying therapy for dementia by 2025. A year later, as we edge slowly towards that goal, we must not forget that good dementia care is possible and that the provision of accessible, high-quality care could allow people living with dementia now to lead longer, more fulfi lling lives. ■ The Lancet Neurology