iSPACE Summary Report April 2015. 6 Steps to Becoming a Dementia Friendly Practice. An evaluation of a pilot initiative implemented in primary care.

1. An evaluation of a pilot initiative
implemented in primary care
Summary Report
iSPACE:
6 Steps to Becoming a
Dementia Friendly Practice
WESSEX ACADEMIC HEALTH SCIENCE NETWORK
CENTRE FOR
IMPLEMENTATION
SCIENCE
Sum
m
aryReport

2. An evaluation of a pilot initiative implemented in primary care
‘iSPACE: 6 Steps to Becoming a Dementia Friendly Practice’
Authors: Sydney Anstee1, Brad Keogh1, Caroline Powell1
1 The Centre for Implementation Science(CIS), University of Southampton,
Faculty of Health Sciences, Southampton, SO17 1BJ

3. p.3
Background
The Dementia Friendly iSPACE initiative was developed
and implemented in April 2014 in a North Hampshire
practice, with funds awarded by the Wessex Academic
Health Science Network (AHSN). The initiative was
adapted from the Royal College of Nursing (RCN)
Dementia 5-step ‘SPACE’ principle for hospital care
to a 6-step initiative called ‘iSPACE’ for primary care:
i-Identify champions; S-Staff training; P-Partnership
working; A-Assessments; C-Care plans; E-Environment.
It was anticipated to generate improvements in
patient and carer experience, teamwork and clinical
consultations. The CIS was engaged to conduct an early
evaluation of this pilot implemented in practice.
Aims:
To assess changes in GP dementia care as a result of
‘iSPACE’ and to make suggestions for possible future
adaptions and roll-out across Wessex.
Methods:
The evaluation used a mixed-methods study to describe
experiences over 6 months in two case-study practices
within Wessex. Methods included:
• Semi-structured interviews with patients and carers
• Structured staff interviews using the Normalisation
Process Theory (NPT) toolkit
• Changes in data related to diagnoses,
referrals, prescribing, care planning
and emergency admissions
• Questionnaire survey amongst a sample
of Wessex practices
Findings:
The evaluation has identified improvements in patient
and carer experience, clinical consultations and care
planning, with the caveat that this study was unable
to control for the effects of other national schemes
occurring simultaneously. Staff delivering the initiative
demonstrated strong commitment to implementing
and sustaining the iSPACE initiative. In addition, the
evaluation has identified benefits in the initiative’s
fit with current guidance, low resource costs and
substantial interest amongst practitioners.
Adaptions to iSPACE include: dementia friendly colour
uniforms and training tailored to specific staff groups.
Conclusions:
The iSPACE initiative has shown: positive improvements
in care, been well received, frequently requested and
considered a user-friendly format. We suggest that
the adaptions be considered additions to the existing
materials and further full evaluation be conducted
following roll-out.
* The NPT implementation toolkit was developed by
Professor Carl May to understand the dynamics of
implementing, embedding, and integrating new
technology or complex initiative.
Executive
Summary

4. p.4 01. Introduction
From the autumn 2014 report Dementia UK estimates that in 2015 there will be 850,000
people living with dementia in the UK. It is forecast to increase to over 1 million by 2025
and over 2 million by 2051, assuming there are no public health interventions and an ageing
population. The total cost of dementia in the UK currently is £26.3 billion; The NHS picks up
£4.3 billion of the costs and social care £10.3 billion.
With numbers of people with dementia rising, dementia
care is a challenge that requires better support for both
people with dementia and their carers, and excellent
links between health and social care.
A pilot initiative for primary care called ‘iSPACE: 6
steps to becoming a Dementia Friendly Practice’ was
developed and implemented in April 2014 by Dr Nicola
Decker, Oakley & Overton Partnership Practice, North
Hampshire, using Accelerator Funds awarded by the
Wessex Academic Health Science Network.
The purpose of the ‘iSPACE’ pilot is to provide steps for
primary care practices to become ‘dementia friendly’
in order to improve the patient journey for people with
dementia and their carers. Its aim is to improve patient
and carer experience, clinical consultations, planning
for future care and teamwork for those working in
primary care.
iSPACE does this by providing bundles of actions in
the following areas:
i S P A C EIdentify
a Dementia
Champion
Staff
who are skilled
and have time
to care
Partnership
working with
carers, family
and friends
Assessment
and early
identification
of Dementia
Care Plans
which are
person centred
Environments
that are Dementia
friendly
The iSPACE initiative as described at the launch of the pilot:
01.
Introduction
IDENTIFY a Dementia Champion in the practice to:
• Implement the iSPACE plan
• Sign up to the Dementia Action Alliance
• Start a spreadsheet of all patients who have
Dementia in your practice
• Read the NICE guidance on Dementia
STAFF who are skilled and have time to care
• Arrange a clinical meeting for GPs with your local
OPMH consultant to discuss your local dementia
pathway and the resources available locally
• Review your practice Dementia QOF template and
make it meaningful to patients

5. p.5
PARTNERSHIP working with carers,
family and friends
• identify carers for all patients with dementia by
sending them a letter via the patient to ask them
to identify themselves.
• Code the carers and ensure they are included
and invited at all stages of the patient’s journey
• Refer the carers to your local carer
support agencies
• Ensure the carers are copied in to hospital referral
letters so that they are aware of appointment
dates (this was the most common request from
patients and carers)
• Give the carer and patient a list of helpful contacts
in your area. We have printed this information out
on business cards – each area will have
different information
• Ensure the carer is offered a health check, flu jab
and that we remind them that they can take a
respite break if needed
• Encourage carers to look at the Alzheimer’s
society website to make use of their
excellent resources
ASSESSMENT and early identification of dementia
• Encourage a culture where dementia is
not stigmatised.
• When someone is concerned about their memory
do a formal assessment and refer if needed
• Offer early support after diagnosis
• Audit all codes such as “cognitive decline or mild
memory disturbance” to ensure they have been
converted to a Dementia code once a formal
diagnosis is made
• Once coded add a “major alert” to the patient
notes so that everyone is aware of their diagnosis
CARE PLANS which are person-centred
• Encourage patients to complete the Alzheimer’s
Society “This is me” document in advance of their
review appointment
• Encourage patients and their carers to express
their care needs at an early stage so that we
make best use of the window of opportunity
(anticipatory care plans are very helpful)
• Be aware of the natural stages of Dementia
and the symptoms of advanced Dementia
• Identify those patients who are progressing
and ensure we link up with social care and add
patients to the multi-disciplinary meeting list
• Refer on to Dementia “post diagnosis
support services”
ENVIRONMENTS which are dementia friendly
• Good lighting, a welcoming face at reception
and a sense of calm
• Uncluttered floor space and plain carpets
• Clear signage for toilets and exits
• Arrange a 1 hour training session for whole team
which focuses on the experience of someone
with Dementia – Dementia Action Alliance or
Alzheimer’s society
• Give each member of staff the booklet “customer
facing staff guide” from the Alzheimer’s society.
(Costs £5 for 25 booklets)
• Encourage staff to watch the online video “insights
on living with and caring for those with Dementia”
by Dr Jennifer Bute (a GP with dementia)
• Continuity of care matters - Allocate one GP to
each patient with Dementia
• Discourage use of antipsychotics - audit this
• Book double appointments for them – they need
more time!
• When they have an appointment add a reminder
to the booking so that someone rings them an
hour before to prompt them to come
Following initial successful development and
implementation of the iSPACE initiative in Oakley and
Overton Partnership Practice, the Wessex AHSN asked
the Centre for Implementation Science (CIS) to carry out
an evaluation of the pilot from May to December 2014.
The aims of the evaluation were to assess the pilot’s
ability to bring about benefits in dementia care and to
provide the Wessex AHSN with recommendations for
any adaptions to iSPACE before formal spread.
The evaluation uses a mixed-methods study to describe
experiences over 6 months in two case-study practices
within Wessex; i) Oakley & Overton practice where the
iSPACE initiative was implemented fully in April 2014,
and, ii) Tower House Surgery where a collection of
dementia initiatives have been implemented through
uptake of national schemes and lead GP ideas.
(Please see section 2 for more details of study
methods and population)

6. p.6 02. Aims and Design of the Evaluation
Outcomes Measurements Timeline Data Source
Patient and Carer Experience
Patient and carer
experience
Qualitative enquiry conducted by lead GPs with
patients and their carers
February/March 2014 and
Oct 2014
Interviews by GPs
Teamwork/Implementation
Teamwork;
Implementation and
sustainability
Qualitative enquiry using Prof Carl May’s NPT Toolkit
[1] to understand the staff dynamics of delivering a
new set of practices (description in section 6)
August to-September 2014 Interviews by CIS Researcher
Clinical Consultations
(diagnoses, referrals, prescribing, care planning, emergency admissions)
Clinical consultations -
better prescribing and
improved referrals
Numbers of patients prescribed anti-psychotics,
memory screened and referrals to Memory Clinic –
also see QOF below
February/March 2014 and
October 2014
Practice provided and
Dementia Challenge *
Care planning for the
future
Use of ‘This is me’ documents or other advanced
care plan package to record important information
February/March 2014 and
October 2014
Practice provided **
Quality and Outcomes
Framework (QOF)
measures
QOF measures relating to diagnoses – the Dementia
Gap and the Dementia Register figures
February/March 2014 and
October 2014
NHS Primary Care Web Tool
data ***
Wessex Survey of Current Practice
Dementia care already
in place in Wessex
CIS Survey of South Wiltshire, Wessex and MARC
Survey of Hampshire and Dorset
August to November 2014 Questionnaire
Data Sources:
*Dementia Challenge Data. ** Practice Provided Data – Oakley & Overton Surgery and Tower House Surgery Ryde. *** NHS Primary Care Tool Data which
uses data from Health and Social Care Information Centre. ** and *** Provided and shared with permissions from the case study practices
02.
Aims and Design
of the Evaluation
The aims of the evaluation were as follows:
i) Assess the pilot initiatives ability to improve dementia
care (patient and carer experience, clinical consultations
and teamwork), and compare with other best practice
ii) Aid Wessex AHSN decision making regarding
possible adaptions and roll-out across Wessex
iii) Monitor informal spread of this initiative through
the duration of the evaluation
iv) Make recommendations for long-term service
evaluation outcome measures
Through consultation a rapid mixed-method
evaluation study was as follows:
Table 1: Outcome measures and methods

7. p.7
Evaluation Population
The patient, carer and staff of the following practices:
• Oakley and Overton Partnership, North Hampshire –
Index case-study practice.
The iSPACE initiative was fully implemented in this
practice in April 2014
• Tower House Surgery, Ryde, Isle of Wight –
Comparator case-study practice.
This practice was chosen as it has also developed a
bundle of dementia friendly actions through uptake
of national schemes and the lead GP’s interest and
enthusiasm for dementia care. The lead GP, Dr Michelle
Legg, is the clinical lead for dementia and older people
at the Isle of Wight Clinical Commissioning Group.
Part-participation:
• Poole Town Surgery – has implemented a number
of actions from the iSPACE initiative and helped
the evaluation team develop appropriate outcome
measures in the early days of the study, but was
unable to participate further due to work
capacity limitations.
Fig 1: Map of Wessex AHSN and evaluation
case-study practices
Fig 2: Population profile at the two
case-study practices
Oakley & Overton and Tower House comparison
Comments:
Oakley and Overton see higher proportion of people
age 60-79 yrs; Tower House see more female patients
aged 80+ yrs; Greater number of males at Oakley and
Overton 40+ yrs; Higher proportion of lower age
groups (0-35yrs) at Tower House.
Legend
Oakley & Overton Partnership
Poole Town Surgery
Tower House Surgery
Wessex AHSN Boundary
CCG Boundary
Legend
O & O Female
Tower Female
Contains
Ordnance Survey
Data ©
Crown copyright
and database
right 2013
O & O Male
Tower Male
0
Percentage of Patients (%)
Age
2 24 46 68 810 10
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85-89
90-94
95+
Please note: All data in this report is
provided and shared with permissions
from the case study practices

8. p.8 03. Full Findings
03.
Full Findings
Summary
iSPACE was an initiative developed and implemented by
the lead GP and her staff at Oakley and Overton and as
such was championed by the key clinician involved in
improving dementia care for the patients and carers at
this practice. The results of the evaluation demonstrate
that iSPACE was fully implemented.
Tower House surgery introduced its own set of dementia
initiatives; some local and some following national
guidance with only a few notable differences from
iSPACE (see full report).
The findings, discussed in more detail in the sections
which follow, from the patient and carer interviews, staff
feedback utilising the NPT toolkit and national and local
data on clinical consultation indicators demonstrate
that the successfully implemented dementia friendly
initiatives in both practices have shown improvements
in all areas. However, for all results, we were unable
to control for any effects of national schemes
occurring simultaneously.
Patients and carers at Oakley and Overton
provided positive feedback on:
• Consistency of dedicated GP
• Having a GP as dementia champion
• Staff who have good understanding
of dementia issues
• Being treated with respect
• Feeling listened to
• Carers feel included and valued
• Better awareness of adherence issues
Patients and carers at Tower house provided
positive feedback on:
• All staff have good understanding of dementia issues
• Big improvements from a few years ago when there
were no dementia services after diagnosis – good
follow-up support is now available
• Excellent care from GP for both patients and carer
Implementation of iSPACE:
The mind-set of staff and culture change is recognised
as key to creating a dementia friendly practice.
Experiences of implementing, integrating and
embedding this new complex initiative were
assessed to be very positive in both practices
with quite similar feedback from each.
All six staff interviewed showed high agreement
with, and understanding of, the purpose, value, and
requirements of the initiative, and how their dementia
services are different with the new initiative to
previous practice.
What differences in patient or clinical consultation
indicators were observed before and after
implementing iSPACE in the two case-study practices?
In addition to the services delivered by the iSPACE
initiative, the project was designed by Dr Decker to
ensure fit with current best practice, one area of which
is early identification of dementia as set out by NICE.
The diagnosis rate is reflected in headline figures
published by the NHS Primary Care Web Tool. When
this initiative began in April 2014 the Wessex local
area had a Dementia Diagnosis Rate of 52.68% (of the
Adjusted National Dementia Prevalence Rate (ANDPR)).
The iSPACE initiative began in the Oakley and Overton
practice in April 2014 with a diagnosis rate of 52.33%
and by October 2014 this had risen to 63.37%. The
Ambition Diagnosis Rate for England by 2015 is 67%.
Tower House surgery figures for patients already
diagnosed with dementia were higher than Oakley and
Overton before iSPACE or this evaluation began. In April
and October 2014 their diagnosis rate was 60%.
In both practices during 2013 and 2014 the dementia
gap and the dementia register show improvements
in the right directions i.e. the gap going down and
the numbers on the register going up, showing that
previously undiagnosed people are now getting
diagnoses and care for this condition. This is a
consequence of the increased numbers being
assessed and referred to memory clinics and
subsequent increases in care plans and
decreases in anti-psychotic prescribing.

9. p.9
Table 2: NHS Primary Care Web Tool Data
Oakley and Overton Tower House, Ryde
APR - 14 OCT - 14 APR - 14 OCT - 14
Practice List Size 11164 11173 10479 10455
QOF Dementia Register 86 105 126 127
QOF Dementia Rate 0.77 0.94 1.20 1.21
NDPR (Num) 177.91 178.66 158.04 161.01
NDPR (%) 1.59 1.60 1.51 1.54
Adjusted NDPR (Num) 164.35 165.69 209.38 212.09
Adjusted NDPR (%) 1.47 1.48 2.00 2.03
Community NDPR (Num) 132.64 133.98 103.30 106.01
Community NDPR (%) 1.19 1.21 1.00 1.03
Care NDPR (Num) 31.71 31.71 106.08 106.08
Care NDPR (%) 57.65 57.65 57.65 57.65
Mild Dementia (Num) 90.36 91.19 114.34 115.62
Moderate Dementia (Num) 53.44 53.86 68.00 68.91
Severe Dementia (Num) 20.55 20.64 27.03 27.57
Dementia Gap (Num) 78.35 60.69 83.38 85.09
Dementia Gap (%) 47.67 36.63 39.82 40.12
Dementia Diagnosis Rate 52.33 63.37 60.18 59.88
Blue shading is measured data from practices; yellow shading is estimations of dementia prevalence based on
population and demography; pink shading is a comparison of the two to find the ‘gap’.
Definitions of figures given above (adapted from the NHS Primary Care Web Tool):
The most important figures in the data above are as follows:
QOF Dementia Register – This is the Quality Outcomes Framework (QOF) figure submitted from GPs of the
number of patients on the GPs list with dementia. It is expected that this is a fairly accurate indication of the
number of people with a diagnosis of dementia in the population.
The Dementia Gap is the percentage of patients on the practice list with dementia who are undiagnosed.
This is calculated by subtracting the QOF dementia register number from the Adjusted National Dementia
Prevalence Rate (aNDPR) number, and expressing that figure as a percentage of the aNDPR. The maximum
Dementia Gap is 100%. (NDPR = National Dementia Prevalence Rate)
The Dementia Gap is the ‘headline’ figure, and represents the percentage of people estimated to have
dementia who are undiagnosed in the community.

10. 03. Findingsp.10
Fig 3: Number of persons currently diagnosed and the Dementia Gap at
Oakley & Overton practice over time
Fig 4: Number of persons currently diagnosed and the Dementia Gap at
Tower House Surgery over time
Persons
DementiaGap(%)
0
2012 - 2013 APR - 14
First
dementia
DES
Jun - 14 Aug - 14 Oct - 14
0
35
70
105
140
20
40
60
80
100
120
140
First
dementia
DES
First
dementia
DES
iSPACE
Initiative
began
Legend
QOF Dementia Register Dementia Gap
Persons
DementiaGap(%)
0
2012 - 2013 APR - 14 Jun - 14 Aug - 14 Oct - 14
0
35
70
105
140
20
40
60
80
100
120
140
First
dementia
DES
iSPACE
Initiative
began
Legend
QOF Dementia Register Dementia Gap
Local data from the two practices was collected over
the six months relating to indicators of dementia care
(8 at Oakley and 5 at Tower House, the two practices
collected slightly different local data due to the
application of different care planning tools): common
indicators included memory screening, referral to
memory clinics, emergency admission to hospital
among people with dementia in the practice, and
use of anti-psychotics (shown in figures 5 and 6 to
the right).
In both practices there is a marked increase in the
number of patients screened for dementia from before
April 2014 to six months later: 1 to 144 in Oakley and
Overton and 17 to 61 at Tower House.
Oakley and Overton showed a decrease in the numbers
of patients with dementia being on anti-psychotic
medication. Tower House remained the same, but
was already at a minimum with only one patient
appropriately medicated with this type of treatment.
Use of the Alzheimer’s Society 'This is me' document
in Oakley and Overton and use of the Tower House
equivalent, ‘Advanced Care Planning’, has increased
markedly in both practices. The information about
patients collected using these planning tools is helpful
to plan, coordinate with carers and to avoid crises in
emergency situations or palliative care.
With the exception of emergency admission there
is an improvement in each dimension. Emergency
admissions of patients with dementia saw small
increases over the time of the evaluation, but it is
reflected that perhaps this measure is too far
removed from the effects of the initiative.

11. p.11
Fig 5: Oakley and Overton -
Before = before April 2014 / After = 6 months
after iSPACE began
Fig 6: Tower House Surgery -
Before = before April 2014 / After = 6 months
after iSPACE began
Memory Screening (DES)
Referral to memory clinic
Emergency admission to hospitals *
Use of anti-psychotics
Use of ‘This Is Me’
Residential Status of Patient (care home)
Power of Attorney in place
Resuscitation status’
After 1441 Before
5
6
7
0
0
2
5 32
18
19
15
4
14
13
Memory Screening (DES)
Referral to memory clinic
Emergency admission to hospitals *
Use of anti-psychotics
Advanced care planning
1
5
1
80 100
1
8
4
After 6117 Before
* Emergency admission to A&E and hospitals, before:
Oct13 - Mar14 and after: Apr14 -Oct14.
* Emergency admission to A&E and hospitals, before:
Oct13 - Mar14 and after: Apr14 -Oct14.
“The response to me when I ring
[as a carer] has improved and
I feel listened to.”
Care planning for the future; Prescribing; Diagnosis/referrals; Emergency Admission

12. 03. Findingsp.12
Patient and carer experience
Baseline interviews at both Oakley & Overton
Partnership Practice and Tower House Surgery were
conducted prior to the iSPACE initiative launch in April
2014. In both practices the interviews were conducted
by the lead GPs with the purpose of learning what
Table 3: Oakley and Overton Practice Patient and Carer Interview Findings:
patients with dementia and their carers required in
dementia care. Interviews were conducted again 6
months later by the lead GPs with a sample of five
interviews observed by the evaluation researcher.
Semi-structured interview questions were used in
both practices. The results from both practices were
similar and are reported in Tables 3 and 4 below.
Time < March 2014 September / October 2014
Participant
Characteristics
16 Interviews:
4 Patients – all male
12 Carers - 5 wives, 3 husbands, 2 daughters,
1 son, 1 niece (1 Pt had 2 carers interviewed)
1 patient recorded as having vascular dementia,
others types – assume Alzheimer’s Disease
11 interviews:
4 Patients – male/female
7 Carers – wives, husbands, other family carers
Interviewer Dr Decker Dr Decker interviewed 7 alone, 4 interviewed
with researcher observing
36% of interviews observed
Patients Patients and Careres
Difficulties Regional accents;
Signs;
Fear;
Embarrassment;
Accepting diagnosis
Positive Feedback:
• Consistency of dedicated GP
• Having a GP as dementia champion
• Staff who have good understanding
of dementia issues
• Respect
• Feeling listened to
• Carers feel included and valued
• Better awareness of adherence issues
Scores: 6 = Excellent 5 = Good
Other learning / Quotes:
Difficult to have dementia and no family, relying
on friends and social
Patient says he’s feeling better – able to talk with
people now; before he was frightened and couldn’t
finish sentences; he feels more confident now and
that has helped improve things; his sleep improved
and nightmares reduced – His GP says he hasn't
actually improved medically, he just feels more
positive and less stigmatised
Patient attributes difficulties to life traumas
rather than dementia
“I’ve got all of it in my brain but it won’t come out of
my mouth sometimes”
Suggestions Sensitive diagnoses;
Consent for carers to be involved;
Fact sheets;
Support agencies;
Enable patients;
Memory Matters course;
Staff training
Works Well Carer makes things ok;
Carer needs to be involved
Carers
Works Well
Already
Memory matters course [x2]
Care at this practice [x4]
Difficulties Dementia advice;
Stress on relationship;
Conversation;
Not admitting diagnosis;
Stigma
Suggestions Involve and support carers [x8]: appointments,
feedback after visit, support outside of practice;
Ensure all staff at surgery are trained, aware of
dementia diagnosis and have identification badges
[x6]; Dementia advice needed - person specific
and general [x4] – to patient, carer and in
waiting room
Room for Improvement
• Signage
• Receptionist forgetting to tell carers about
appointments – especially difficult when several
carers to include (social carers and friend/
family carers)
• Anticipatory care

13. p.13
Table 4: Tower House Surgery Patient and Carer Interview Findings:
Time < March 2014 September 2014
Participant
Characteristics
4 pairs of Patient and Carer together
Carers: wife, son, daughter and unspecified
relationship. Age ranges 71-89
3 interviews including
1 Patient
2 Carers
Interviewer Dr Legg 2 Interviewed by Dr Legg alone - 1 interviewed
with researcher. 33% of interviews observed
Patients Patients and Careres
Difficulties Housebound – unable to go to GP Practice; Long
wait for hospital referral; Lonely; Worry about
future (getting worse)
Positive Feedback
• All staff have good understanding of
dementia issues
• Big improvements from 5 yrs ago when there
were no dementia services after diagnosis –
good follow-up support is now available
• Excellent care from GP for both patients
and carer
Scores: 2 = Excellent 1 = Good
Researcher observations in waiting room:
• Bright, uncluttered and spacious waiting room
• Distinctive and recognisable dementia
champion in pink uniform
Other learning:
A dementia diagnosis can be a shock for the carer,
and transition from one role to another is difficult
Difficult to have dementia and no family, relying
on friends, community and social care – for
example one patient says she is lonely, worries
about shopping sometimes and worries a lot
about the future
Suggestions More appointment availability with own GP;
More information
Works Well GP and staff are friendly
Carers
Works Well
Already
Staff friendly and approachable;
GP is involved with dementia;
Can phone and speak with someone;
Dementia gaining public recognition;
GP home visits;
Care navigator
Difficulties Long waiting for diagnosis referral and Social
Services;
Do not feel confident that all staff are approachable;
Cognitive Behavioural Therapy (CBT) referral too
far away;
Carer relief hard to access;
Don’t feel valued;
Stress;
Suggestions
(Continued)
Environment [x3] - Waiting room, signage, colours
Dementia special staff identified and clear [x2] –
Admiral nurse/champion/logo
Investigations for diagnosis needs to be accurate
More activities to stimulate memory; Continuity –
one doctor per patient; Care plans
Support with getting lasting power of attorney
Prescriptions made easier using dosette boxes
Shops more supportive, help with money
[out of GP remit]
• Long waiting times in reception is difficult
for carer when accompanying a patient
with dementia
Dr Decker suggests immediate possible
solutions to above:
• We can address long waiting times by having
patients booked in at the beginning of surgery,
or, have things in the waiting room to occupy
patients, or let reception know so GP can juggle
things, or include volunteers in the practice
• Reception is constantly being improved, clearing
posters, better signage and reception staff
always at the desk
• Staff will be reminded of importance of carer
inclusion with flu jab appointments

14. 03. Findingsp.14
Suggestions
(Continued)
Social workers and GPs work together;
Send mail to/call carer not the patient [x3];
Chose a GP;
Dementia adviser based at the practice;
Dementia advice to carers; More information in
waiting room
Room for Improvement – Patient requests
• More leaflets in waiting room
• Regular GP initiated check-ups
• More availability with a named GP
• More community support needed
Immediate help offered:
The kind of support wanted is available
and the patient was given leaflets
Problems outside the GP remit:
Social isolation and transport
When comparing the summaries of interviews pre-
initiative and six months later (see Tables X and X), it
would appear that both surgeries have been able to
address most of the patient and carer suggestions
for improvements. Particular areas of improvement
include:
• Staff understanding of dementia and ability to
address specific issues. Dementia champions
are key to facilitating these changes
• Carers are included and valued – this is vital for
patients with memory problems
• Signposting to social care and community facilities
bridges gaps between health and social care and
increases support complimentary to both
Patients and carers at practices have reported a
majority of excellent ratings (6/11 Oakley & Overton;
2/3 Tower House) and the ‘room for improvement’
areas are generally outside of the GP remit e.g. social
isolation, although both practices are able to sign-post
to local services where they exist.
Overall we conclude that patient and carer experiences
have improved in both practices where dementia
initiatives to improve care have been implemented.
However a note of caution:
• GPs conducted the interviews with a sample
observed by the researcher
• Repeat interviews were conducted a very short time
after the iSPACE initiative had been implemented
with limited lead-in time for the initiative to become
imbedded in practice
• Due to time and resource constraints validated patient
experience tools were not used. Locally developed
tools fit for purpose were used
Experience of staff implementing
new dementia care
Primary Care Practice Staff Interviews using
Normalization Process Theory (NPT) Toolkit:
Primary care practice staff interviews were conducted
by the researcher using Normalization Process Theory
(NPT) Toolkit . Each participant answers 16 questions
on a sliding scale of agreement, low-high (questions
can be seen in the link above). Whilst each participant
is considering their answer and discussing issues
with the researcher, their dialogue is recorded for
later analysis.
When the participant has completed the questions, a
results summary is presented as a radar plot (see Fig 7
below) to illustrate how well areas of implementation
are achieved.
Problematic areas can be identified easily through the
areas close to the centre of the plot and corresponding
dialogue in the recording/transcription.
To assess validity of findings, we carried out a member-
checking process, confirming whether findings were
correct and consistent with each participant’s view.
Consent forms were returned on completion of
this process.
“It is a relief to be able to make an
appointment and know it will be
with the same doctor and I don't
have to negotiate this."
“There have been improvements in
the approach by staff and they have
been more understanding.”

15. p.15
Fig 7: NPT results summary for one member of staff in Oakley and Overton Practice
Toolkit results : Results Generated on 04/09/2014
100
35
75
60
Monito
ring Sens
eMaking
Parti
cipation
Acti
on
0
1
0
2
3
100
35
75
60
0 5
4
6
7
100
35
75
60
0 9
8
10
11
100
35
75
60
0 13
12
14
15
100
35
75
60
0
Results
The Radar Plots show the strength that you have assigned to each
variable. Use them as hueristic tools to think through an implementation
or intergration process. Potitive responses extend further out from the
centre than negative ones. Look for areas where the responses are closer
to the centre. These may tell you that participants cannot make sense, or
have not signed up to the innovation. Perhaps they cannot enact it in a way
that works for them, or cannot assess its effects and their values. If the
responses are positive, the oppostire may be true.
Sense Making
1. Participants
distinguish the
intervention from current
ways of working.
2. Participants
collectively agree about
the purpose of the
intervention
3. Participants
individually understand
what the intervention
requires of them.
4. Participants construct
potential value of the
intervention for their
work.
Participation
5. Key individuals drive
the intervention forward.
6. Participants agree that
the intervention should
be part of their work.
7. Participants buy in
to the intervention.
8. Participants
continue to support
the intervention.
Action
9. Participants perform
the tasks required by the
intervention.
10. Participants maintain
their trust in each other’s
work and expertise
through the intervention.
11. The work of
the intevention is
appropriately allocated
to participants.
12. The intervention is
adequetly supported by
its host organisation.
Monitoring
13. Participants access
information about
the effects of the
intervention.
14. Participants
collectively access
the intervention as
worthwhile.
15. Participants
individually access
the intervention as
worthwhile.
16. Participants modify
their work in response
to their appraisal of the
intervention.
As both practice findings were so similar, they have been
combined and condensed together, with differences
specified where necessary. These are reported under
the relevant headings from the NPT toolkit.
Sense Making:
In both practices all 6 staff interviewed showed high
agreement with, and understanding of, the purpose,
value and what the initiative requires of them. All are
aware of how their dementia services are different with
the new initiative to previous practice.
Participation:
All staff agree that there are key people who have
driven the initiative forward. One staff member
comments that they “can’t imagine being without it,
it would be a disservice to patients not to have it”.
There is high willingness to participate in this
initiative but capacity can be a challenge.
Action:
The staff interviewed agree that they do the tasks they
are allocated; trust each other to carry out their tasks,
and individual actions in the initiative are appropriately
allocated to staff.
A few issues were raised: in Oakley and Overton practice
the same training is delivered to all staff regardless of
role and frequent “nudges” are needed to carry out
appointment reminders. In both practices concerns
were raised about the major risks to continuation
which are high primary care workload and future
political priorities.

16. 03. Findingsp.16
Monitoring:
None of the staff were aware of any formal evidence
on effectiveness; however, all agreed they were able to
observe positive differences in interactions in the clinic
and community, and in appreciation voiced by patients.
Staff strongly agree that the initiative appears
worthwhile and all felt that if they have ideas for
improvement they are encouraged to make their
suggestions.
The mind-set of staff and culture change in practice
have been recognised in both practices as vital to
creating dementia friendly practice in primary care.
Experiences of implementing, integrating and
embedding this new complex initiative were assessed
to be very positive in both practices with quite similar
feedback from each.
All staff showed high agreement with and
understanding of the purpose, value, individual and
collective contributions and abilities. In addition all
were already witnessing the positive effects of the
initiatives in the practice population and are
committed to continuation.
Adaptations in practice between Tower House
and Oakley & Overton:
• Training tailored for staff types is thought to
be beneficial
• Appointment reminders and double appointment
times are not fully embedded in either
• Significant risks to the continuation of enhanced
dementia care are identified as workload and
political priorities
The Survey of Wessex Practices
At the same time as the CIS were ready to survey
Wessex, the Wessex Strategic Clinical Network (SCN)
Dementia Diagnosis Project Group in collaboration with
Bournemouth University Dementia Institute (BUDI) and
the Memory Assessment and Research Centre (MARC)
launched a project to include two surveys and a focus
group, in Hampshire and Dorset.
In collaboration, the CIS evaluation agreed to survey
only South Wiltshire and the MARC agreed to include
questions and information on iSPACE in their survey
to all Hampshire and Dorset practices. Their practice
manager survey finished mid-December 2014: A total of
39 practices were surveyed throughout Hampshire and
Dorset by MARC.
The CIS iSPACE survey was sent to 26 practices mid-
August 2014. Two reminders were sent and the survey
closed mid-October 2014. A total of 4 responses were
received = 15% response rate.
Half were sent a long version of the questionnaire
= 3 responses; half were sent a short version of the
questionnaire = 1 response.
Although the number of responses to the survey was
not high, the ones received showed that many of the
actions involved in the iSPACE initiative have been
implemented in the respondent practices.
Amongst the respondents there was low awareness of
either SPACE in general hospitals or iSPACE in primary
care before receiving the questionnaire. The areas
showing low implementation are generally areas that
require more time and resources than others e.g. staff
training, booking double appointments.
However, we found that many of the iSPACE actions
were already in place, which was anticipated due to the
intervention providing a good ‘fit’ with current practice
and national guidance.
“If mum comes to the surgery on her
own and I send a note I have always
received some feedback from the
health professional she has seen.”

17. p.17
Fig 8: Survey results from South Wiltshire practices:
Primary Care Practices were asked the following questions:
Has your practice....
Heard of the RCN Dementia SPACE scheme before (in hospitals)?
Heard of ‘iSPACE’in primary care before receiving this questionnaire?
Signed up to Dementia Action Alliance?
Created a record of patients with Dementia?
Actioned/read the NICE guidance on Dementia?
Regular clinical Dementia meetings for GPs and local OPMH consultant?
Regularly review Dementia QOF to ensure it’s meaningful to patients?
Have whole team training on the experience of someone with Dementia?
Provide staff with“customer facing staff guide”from Alzheimer’s Society?
Staff watch“Insights on living with and caring for those with Dementia”?
Allocated one GP to each patient with Dementia for continuity of care?
Audit & discourage the use of anti-psychotics?
Identify and write to carers for all patients with Dementia?
Code carers to your local carer support patients?
Refer carers to your local carer support agencies?
Copy carers in to hospital referral letters / aware of appointments?
Provide carers with a list of helpful contacts in your area?
Carers offered health checks, flu jabs and guidance on your respite breaks?
Tell carers about resources on Alzheimer’s society and other orgs?
Encourage a‘Dementia friendly’culture?
Offer Dementia assess / referrals if someone is worried about memory?
Offer early support after diagnosis?
Audit correct codes changes from memory-dementia after diagnosis?
Add‘major-alert’to the patient notes to make aware of diagnosis?
Book double-appointments for patients with Dementia?
Add notes to patient bookings to prompt reminder an hour before appt?
Ask patients to complete Alz’s Society‘This is Me’doc before review appt?
Ask patients for their care needs early on to aid anticipatory care plans?
Explain natural stages of Dementia and symptoms of advanced Dementia?
Identify patients who are progressing and ensure link-up with social care?
Add progressing patients to the multi-disciplinary meeting list?
Refer patients to Dementia‘post-diagnosis support services’?
A welcoming face at reception and sense of calm?
Uncluttered floor space and plain carpets?
Clear signage for toilets and exits?
Noticeboard with information for the public about dementia?
Do you think iSPACE is useful / easy to use?
i. Identifying Dementia Champions
S. Staff who are skilled and have time to care
P. Partnership working with carers, family & freinds
A. Assesment and early identification of Dementia
C.Care plans which are person centered
E. Environments that are‘Dementia Friendly’
0 50 100
YES%

18. 03. Findingsp.18
Additional areas of benefits from iSPACE
which the evaluation has identified?
• Good fit with current guidance
The initiative has been received as complimentary to
current practice guidance. We found that iSPACE can
usefully facilitate implementation of other guidance,
for example,
“it provides user-friendly format for implementing
services such as the national dementia DES or NICE
guidance”; “It is useful to plan actions and to categorise
areas where changes can be made”
• Low costs in terms of time, money and
resources to implement:
“The iSPACE concept is easy to follow and can be done
without significant costs” (Dr Legg).
Feedback from staff during the evaluation suggest the
initiative is not expensive to implement and many items
in the bundle of actions may already be in place as a
result of implementing other current practice guidance
such as that of the King’s Fund or NICE. It has also been
noted that as it is quick to implement, it is low on
resource costs too.
“It provides structure and reproducibility in making
primary care practices dementia friendly” (Dr Legg).
What improvements could be made
to iSPACE?
The evaluation has shown that some possible adaptions
to iSPACE based on the Tower House Surgery model
may further enhance dementia friendly care, such as:
• Dementia friendly colour uniforms and interior
decorations (King’s Fund guidance) for ease of
identifying dementia champions (possibly more than
one as demonstrated at Tower House Surgery)
• Training which is tailored to different staff groups
within primary care
• Primary Care practice staff acting as Dementia Haven
for the community, as this further strengthens links
between primary and social care
The above form the CIS recommendations for adaption.
Other local tailoring will be at practice level discretion.
Dr Legg comments that “simple, low-cost things can
make a big difference for patients and carers, e.g.
colours and signs”, and refers to guidance here:
http://www.kingsfund.org.uk/projects/enhancing-
healing-environment/ehe-design-dementia
Both GPs have commented in the NPT interviews that
iSPACE is cheap and quick to put in place.
• During the evaluation there has been substantial
interest amongst practitioners and informal spread
of the initiative. The implication of this across Wessex
is the potential for high- impact in dementia care.
(See Informal Spread in section 5)
“I like the fact that the GP will do
the annual check-up for dementia
as mum is more comfortable with
this person rather than going to
the hospital to see someone she
doesn't really remember.”

19. p.19
04.
Proposed Next Steps
& Recommendations
for Formal Roll-out
Adaption
In general the materials developed by Dr Decker
have been well received, frequently requested and
considered a user-friendly format; therefore we would
suggest that any adaptions could be considered
additions to the existing materials.
Any adaptions or further developments to iSPACE
should keep this following statement given by
Dr Decker in mind:
Further Engagement and
Roll-out Plan
The Wessex AHSN will continue responsibility for the
spread of the iSPACE initiative as part of their Quality
Improvement Programme in Dementia – The following
has been provided courtesy of Katherine Barbour,
Senior Project Manager:
The Wessex AHSN plan to roll-out this initiative to a
further 40 practices across Wessex in 2015/16.
On average each practice now cares for approximately
10,000 patients. If the Wessex AHSN reaches its target
of 40 practices this will equal around 400,000 people
registered in dementia friendly surgeries. This could
potentially impact around 5200 people with dementia
(based on population prevalence 1.3%
(www.alzheimers.org.uk 2014))
and a minimum of 5200 carers.
The Wessex AHSN is currently planning to use a wide
variety of methods to reach their target roll-out.
We suggest that the AHSN / CIS continues to request
practice level data as identified in section 4 and utilises
this to monitor progress of the roll out and the impact of
the adapted iSPACE on patient care.
Details can be obtained by contacting Katherine Barbour
at the Wessex AHSN - http://wessexahsn.org.uk/
In addition regular recording of the dementia data
indicators ( as shown in the full report fig.10) and a
comparison of the diagnosis rates with the dementia
gap could be useful monitoring tools to be deployed in
each practice during roll-out.
“The interventions’ aims would be improved
care planning which in turn will hopefully
result in less crisis admissions and a greater
number of people “living well” with dementia
in the community”

20. p.20 05. Informal spread of iSPACE during the evaluation
05.
Informal spread of
iSPACE during the
evaluation
The spread of the iSPACE initiative appears
to be gathering momentum, as noted in
the numbers of organisations who have
requested the materials to aid set-up of
enhanced dementia care services
(see Table 5 to the right).
In addition, every conference or event regarding
dementia, where the iSPACE initiative has been
presented during this evaluation, has either been fully
booked or oversubscribed. This demonstrates the
demand and interest in this area is substantial.
There is no inference that this initiative should
become part of policy following this evaluation, but
if practitioners wish to adopt the initiative into their
practice this will be fully supported by both this
evaluation and work planned to continue by the
Wessex AHSN.

21. p.21
Date Actions Results
April 2014 Launch of Hampshire’s first dementia friendly GP
surgery at Oakley and Overton Partnership surgery,
N Hants
This was picked up by the Basingstoke Gazette,
Pulse and tweeted about by Dr Alistair Burns,
clinical lead.
May 2014 This initiative was described on Linked In dementia
friendly GP surgery
16 comments from around the world and resources
shared with colleagues in New Zealand, Minnesota
USA, Norfolk CCG, Queensland University of
Technology Brisbane, Know Dementia (West
Sussex), linked to Purple Angel
Norfolk CCG are using the initiative
May 2014 This initiative was described in the Wessex
AHSN newsletter, The Wire
Two surgeries in Wessex requested the initiative:
Littledown Surgery, Bournemouth
Westlands Medical Centre, Portchester
August 2014 The iSPACE survey sent to south Wiltshire primary
care practice managers
See the Evaluation Report for Results
26 South Wiltshire practices were sent information
about the iSPACE initiation
September
2014
LMCS half day training session on Dementia. Dr
Nicola Decker presented this work to the 140 GPs
in attendance
This talk was published on the LMCS
October 2014 Verity Turner GP (ST4 quality improvement fellow)
working in conjunction with West Hants CCG and
Dr N Decker offered to work with a number of
surgeries to implement the dementia friendly
surgery. An evaluation is also being conducted of
this work.
Three surgeries signed up in West Hampshire
CCG: Fryern Surgery in Chandlers Ford, Arnewood
Practice in New Milton and Blackthorn Health
Centre in Hamble.
October 2014 Andover Mind has the lead for dementia friendly
communities in Hampshire and requested this work
Unknown
October 2014 Dr Emer Forde part-implemented iSPACE in
Poole Town Surgery and shared initiative as
'gold standard' with others in the Poole area
7 further practices have access to the
initiative materials
October 2014 National Dementia Congress – Dr Decker and
Katherine Barbour presented this initiative and
preliminary results from the evaluation
The session was attended by approx. 50 people
and specific materials requested by 4
October 2014 Dr Michele Legg appointed clinical lead for
dementia programme with Wessex AHSN
Dr Michele Legg shared this initiative with
other GPs on the Isle of Wight
Sept-Oct 2014 MARC/SCN conducted interviews with 39
Hampshire and Dorset practices
38 Practices who had not heard of iSPACE
before were sent the initiative materials
November
2014
iSPACE featured in the Alzheimer’s Society
online magazine
Alzheimers Society
December
2014
Pippa Foster Operations Manager, East Midlands
West (Nottinghamshire & Derbyshire) Alzheimer's
Society is working to make primary care services
in this area dementia friendly and has funding for a
project in 2015
The iSPACE initiative is the first reference in the
Project Initiation document
Table 5: Informal spread of iSPACE during the evaluation
Table 5 has been provided courtesy of Katherine Barbour, Senior Project Manager, Quality Improvement Programme in Dementia:

22. p.22 Acknowledgments
Acknowledgements
We wish to thank all the following for their help in
designing and conducting this evaluation:
Nicola Decker, Lead GP and all the staff, Oakley &
Overton Partnership Practice; Katherine Barbour,
Wessex AHSN senior programme manager; Michelle
Legg and all the staff, Dementia Lead GP, Tower House
Surgery; Emer Forde, Lead GP, Poole Town Surgery;
Prof Judith Lathlean, academic adviser, (UoS); Carol
Rivas, academic adviser, (UoS); Dave Evenden, data
support; Prof Anne Bowling, academic adviser on
patients and carer interview questions, (UoS); Suzanne
Dodge and Rebecca Ollington, MARC, Hampshire and
Dorset questionnaire; Deborah Noakes, NHS Wiltshire
CCG, Questionnaire facilitation; Prof Carl May, academic
adviser, (UoS); Dawne Garrett, Professional Lead, Royal
College of Nursing (SPACE); Bournemouth University
Dementia Institute (BUDI), Michelle Heward and Clare
Cutler; Hazel Orriss, Administrative support; Wessex
Strategic Clinical Network Dementia group, especially
Chris Kipps and Paul Hopper; NICE Implementation Field
Consultant, Stephen Judge; Christina Cleworth, The
Adams Practice, Dorset.
We extend especially grateful thanks to all the patients
and carers who took part in this evaluation, all of whom
are of key importance in this work and to the health care
that will follow.
References in this summary document:
1. May CR, Finch T, Ballini L, et al. Evaluating complex
interventions and health technologies using
normalization process theory: development of
a simplified approach and web-enabled toolkit.
BMC health services research 2011;11:245
doi: 10.1186/1472-6963-11-245.
For a PDF version of this Summary or the Full report
please go to:
www.southampton.ac.uk/wessexcis/
or
http://wessexahsn.org.uk/

23. p.23

24. Centre for Implementation Science (CIS)
Faculty of Health Sciences,
University of Southampton
Building 67
Highfield
Southampton SO17 1BJ
Email: WessexCIS@southampton.ac.uk
Tel: 023 80 59 7845