Introduction

As provided by the previous draft of the client’s file.

Demographic and Epidemiological Profile of Brent Population

According to Brent Joint Strategic Needs Assessment (JSNA) report that was released in 2014, dementia is the second leading cause of death in Brent. This report also indicates that Brent was ranked first among the existing boroughs in London with a high prevalence of dementia and was followed by Enfield and Haringey by the end of 2014. Moreover, the Brent JSNA 2014 also states that the Non-White residents at the age bracket of 55-79 years were reported to be the most profoundly affected population in the communities profile of Brent which was relatively higher than Enfield where the Non-White residents diagnosed with dementia were between 65 and 88 years old. Moreover, the 2015 Marmot report states that the prevalence of dementia in Brent was 35% of the total population in this outer borough by the end of 2015 thus making it relatively higher than the national average in England which was at 27%.

Long term conditions and Chronic Illness Trajectory

According to the National Health Service in England, delivery of high-quality care for patients with long term conditions is still limited, and there is the need for standardisation of care delivery across the country. The recent findings by the Clinical Commissioning Group(CCG) indicated that most of the patients seeking health care services in England are those who are suffering from long term conditions such as cancer, dementia, arthritis and heart diseases with dementia being the most common across the majority of the outer boroughs in London, England. At present, approximately 750,000 people are living with dementia across the country with this number expected to increase to more than one million individuals at the start of 2026.

The chronic illness trajectory framework developed by Corbin and Straus (1991) can be used in discussing dementia as one of the long term conditions that are affecting residents in the United Kingdom.

As illustrated by the chronic illness trajectory framework in the appendix 1, there are nine phases of dementia. Firstly, there is the pre-trajectory phase in which most victims of dementia in Brent are not yet diagnosed with these long term conditions. However, as time and age progresses, individuals start developing complex complications such as depression and memory loss thus resulting in the onset of this disease. At this stage, the patients are diagnosed with this ailment, and they start experiencing insidious symptoms over time which are however relatively under control. The fourth phase of dementia involves the development of complications in which the patients start exhibiting continued deterioration in health status. The complex health needs then gradually become acute and there is a high chance that the patient gets hospitalised.

The emergence of health crisis mark the sixth stage in which the health condition of the patient who has dementia becomes critical, and the patient is unable to conduct most of the daily activities. However, various medical interventions such as therapy and drugs help in bringing the patient into a stable condition thus marking the seventh stage which involves psychologically coming into terms with the current health condition and limitations that are eradicated through rehabilitative procedures among other health care measures. Given that dementia is a terminal illness, the patient starts to experience continued degradation in the quality of life and health status thus resulting in the downward phase. Lastly, the immune system of the dementia patient deteriorates during the finals before death thus slowly culminating to death.

Patients who have dementia are also found to be critical victims of co-morbidity health issues whereby they tend to suffere from more than one disease.

Determinants of Health in Brent

According to the 2015 Marmot review, housing is one of the critical determinants of health in Brent whereby poor housing in this borough has significantly contributed to poor health status amongst the residents especially those suffering from long term conditions such as dementia. Secondly, education is also determining the quality of health that residents in Brent can access with most of the illitrate having a shallow knowledge about their medical requirements. Moreover, the level on income and employment also determines the health status of the residents in Brent whereby individuals with high paying jobs have extra disposable income which they can use to seek the costly health care services needed to deal with the complex health care needs of the patients with long term conditions such as dementia.

Improving the quality of life, reducing the number of individuals living with dementia and reducing costs incurred while seeking care for dementia among other long term conditions are some of the critical measures that help in positively changing the trajectory of dementia in Brent and the United Kingdom as a whole. Provision of treatment that is aimed at delaying the onset of dementia by a period of five to ten years can significantly contribute to a reduction in individuals living with this terminal ailment by a third before the start of 2050.

Health and Well-Being of Older Adults with Dementia

Individuals who have 60 years and above are the most vulnerable population to dementia among other long term conditions. Individuals with good health and well-being are considered to have a high quality of life and are able to undertake various activities of daily living on their own. The mental health status of older individuals keeps on deteriorating as they continue ageing. Ageing is one of the key contributors to poor health and well-being and also increases the prevalence of chronic diseases. Co-morbidity is becoming common amongst older individuals diagnosed with dementia whereby they have also been found to suffer from other diseases such as hypertension, Alzheimer and depression.

The poor mental condition of older patients diagnosed with dementia makes it hard for them to perform activities of daily living. Dementia has severe effects on the brain cells of the older people and has detrimental impact on their health and wellbeing.

Barriers to engagement and strategies to overcome

Various factors hinder individuals diagnosed with long term conditions from actively engaging themselves with healthcare within the United Kingdom. Firstly is cultural differences within the country whereby citizens in England come from diverse cultures which have different perceptions and beliefs about health care that is delivered within the health settings with some individuals opting for traditional methods rather than the modern methods of health care.

Secondly, health care settings are unevenly distributed across the country thus making it hard for individuals located in rural areas from having better access to medical cares. According to the 2015 Marmot health care indicator, individuals suffering from long term conditions such as dementia and who are located in rural areas have limited access to hospitals. Thirdly, the Black Report of United Kingdom indicates that most of the individuals suffering from long term conditions are unable to engage themselves with health care services due to unequal distribution of resources and job opportunities in the country thus leading to high levels of health inequality in the country.

Fourthly, the presence of different social and economic classes in England has significantly influenced the level of health engagement whereby people in the lower socioeconomic groups and who are living with long term conditions such as dementia rarely engage with health care services due to high costs involved. Moreover, older people whose age is 65 years and above and who are suffering from long term conditions are highly distracted from engagement with health care due to the presence of high levels of negative stigma from the public.

However, various interventions can be employed in the effort of eradicating the high barriers to engagement with health care. For instance, the government can introduce new policies in the healthcare that will see to it that more health care facilities are built across the country especially in the rural areas where they are significantly few. Secondly, increasing public awareness about the detrimental effects of failing to seek care services from professionals in the health care settings can help in facilitating increased acceptance of the long term conditions and reduce the level of stigmatisation that patients especially the older adults diagnosed with terminal disease face in the society. Thirdly, increase in job opportunities can help in boosting the level of engagement of the long term condition patients who are in the lower socio-economic status.

Policy Content

There are several national and local policy and initiatives to address dementia and long-term conditions. which is characterized by lower chances of accidents and risks which are common for individuals diagnosed with dementia. In 2010 to 2015 government policy on dementia (2015) emphasised on three main action areas: improvements in health and care, improving dementia research and creating dementia friendly communities. The National Health Service (NHS) has made integration of support self-care and effective management of individuals living with long term conditions part of its core strategy of improving health care in England(Goodwin et al., 2010, pp.13). Moreover, the establishment of the National Service Frameworks in England has resulted in the formulation of national standards and identification of critical interventions such as home care services for people living with long term conditions such as dementia in the country.

Needs of People with Complex Care Needs and Interventions

In the United Kingdom, there still lacks a “one-size-fits-all” approach that can be used to enhance and support individuals living with long term conditions. The absence of such an approach is facilitated by the fact that each of the patients with terminal diseases such as dementia has care needs that are entirely different from those of another person.

According to the recent findings by the Joint Strategic Needs Assessment in Brent, older adults with 65 years and above and who are living with dementia are faced with the numerous mental health issue such as depression.

This section of the population is profoundly depressed due to their continued dependency on other people for both major and minor activities of daily living which makes them feel worthless and unwanted. Depression is facilitated by their weak health which affects even their motor skills.

Another involved health need of the older adult diagnosed with dementia isloneliness and feelings of isolation whereby patients with the limited movement and continued deterioration leaves most of these patients hospitalised thus limiting their freedom to socialise with others hence resulting to low levels of life satisfaction.

Several interventions can be implemented in the effort of meeting the above complex care needs of individuals living with long term conditions such as dementia. For instance, the physicians can introduce person-centred services that primarily focus on specific complex health care needs of each patient given the facts that these needs tend to vary from one patient to another. Secondly, the provision of vocational rehabilitation can help people living with long term conditions such as dementia manage to improve their health status through the special care that is provided in these institutions. Moreover, the clinicians and caregivers can collaborate in ensuring that patients receive specialist rehabilitation and ensure that the NICE Guideline which was published in June 2018 is strictly followed to the letter as it set some principles and measures that can be developed in facilitating active recovery of patients with complex care needs.

Roles of the Nurses in Promoting Holistic Care

Nurses are the primary actors in facilitating the adequate provision of care services to the patients within a hospital setting. One of the most significant roles that they play in providing holistic care to patients with long term conditions such as dementia. Comprehensive care helps in supporting the continuous healing of mind, soul and body of the patient. Nurses are responsible for implementing a person-centred or social model of care as described by the below model.

Figure 1: Social or Person-Centered Model of Care

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Provision of person-centred care by the nurses helps in supporting the level of independence and dignity of the individuals suffering from long term conditions especially the older adults who mostly suffer from multiple complications. The social care model also focuses on creating a conducive, more active and homey environment for the dementia patients especially the older adults who have complex health and care needs. Some of the critical components of the person-centred solution to health care needs of dementia patients in Brent and other parts of the world include the provision of web-based training, partnering with family care providers, geriatric care management and dementia care competency training to those with complex care needs.

Moreover, nurses are actively involved in implementing the Kaiser Permanente Health Care Model within the clinical setting. Kaiser Permanente model ensures that there is effective collaboration between the nurses, physicians and other professionals in facilitating integrated health care plan that meets the complex health and social care needs of the patients with dementia and other long term conditions. The nurses are currently using this unique system as a critical intervention in meeting the complex needs of the patients. It helps the nurses ensure the active electronic flow of medical information of the patients, from the clinical to the primary and speciality care for informed decision making by the care providers. The Kaiser Permanente system of care has enabled the nurses to focus on care management, prevention and health education of the patients living with long term conditions thus facilitating their quick recovery and prolong their lives.

To provide holistic care to dementia patients in Brent, nurses are required to critically understand the various stages of dementia to help them determine which kind of attention to offer to the patient depending on the care needs. A proper understanding of the critical signs and symptoms of dementia in patients also helps the nurses to take timely medical actions that can help promote quick recovery.

Another essential role of the nurses is conducting a biopsychosocial assessment of the patients living with long term conditions such as dementia in the effort of determining various psychological, biological and social needs of the patients. This assessment is essential as it helps the nurses and other care providers effectively identify the risks involved and take immediate action or medical intervention. The below image shows the biopsychosocial framework used by the nurses in providing a holistic assessment of the patient.

Figure 2: Biopsychosocial Model

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Additionally, nurses are responsible for supporting quick recovery, promoting safety and sustaining the well-being of the patients with long term conditions especially the older adults who have dementia. As illustrated by the below triangle of care, it is vital for nurses to ensure that there exists a therapeutic alliance or collaboration between the caregivers, professionals and services users with the help setting.

Figure 3: Triangle of Care

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Palliative Care

Nurses have a significant role in providing palliative care which is considered as an interdisciplinary approach that focuses on facilitating nursing and specialised medical care for those patients with long term conditions such as dementia. Palliative care is aimed at ensuring that the nurses and care providers can reduce mental stress, physical stress and pain in patients with terminal diseases thus improving the quality of life of such individuals. Palliative care is very crucial to older adults with long term conditions such as dementia, and it helps in ensuring that all their complex health and social care needs are met.

Communication Strategies for Escalation of Care

Effective communication amongst the multidisciplinary team in the primary, secondary and tertiary level is critical in facilitating delivery of person-centred and holistic care to patients living with long term conditions such as dementia (Varcarolis, 2016, pp.4). Poor communication amongst the health professionals may result in misinterpretation of important information thus contribution to uninformed health care decisions. Multiple modes of communication are required in facilitating the delivery of holistic care for older adults living with dementia in Brent.

Some of the strategies that are part of these multiple modes include the used phone, face-to-face communication or emails and hard copy writings (Varcarolis, 2016, pp.75). Moreover, with the current technological advancement, effective communication amongst the multidisciplinary team in health settings within Brent can be facilitated through the use of automated data acquisition and data reminders, the electronic health records (EHR), patient education modules and remote physiologic monitoring techniques. These digital communication strategies have shown to be reliable in facilitating the timely delivery of information to the right recipients (Varcarolis, 2016, pp.79).

The dementia care pathway for Brent provided in Appendix 2 of this paper provides clear toolkit and guidance on how care can be provided to individuals living with this long term condition. This pathway maps out the care roadmap that a patient who has been diagnosed with dementia is supposed to follow plus also provides an aide-memoire for different support services that are required by patients from the time they are diagnosed with dementia until the end-of-life care. It has become part of the clinical governance and regulation that all the health care settings put into place effective communication strategies that will see a smooth and continuous flow of information from the sender to the recipient within and across all departments within the hospital.

Strategic Plan for Accessing Local Community Needs

Individuals living with long term conditions in Brent are faced with a variety of local needs that affect the entire community. The recent findings indicated in the Brent Joint Strategic Needs Assessment (JSNA) report show that more than 68% of the people with complex health care needs in Brent and other boroughs in London are suffering multiple concurrent chronic conditions, social vulnerabilities, mental health challenges and functional and cognitive impairments. High inaccessibility of medical services by the older adults with complex health care needs dementia particularly in Brent has become a critical local problem due to the high costs involved and location of healthcare settings.

Secondly, high levels of unemployment in Brent have significantly increased poverty in Brent thus contributing to the continued deterioration of the health status of most of the residents in this borough particularly the older adults whose most of the complex health and social needs are not met. Poverty makes it hard for most of the people living with complex health and social needs to have access to better care services. Moreover, the presence of different social classes in Brent has also resulted in high levels of health inequality. People in the higher socioeconomic status who are mostly the White Englishmen have better access to care when compared to their counterparts in the lower socioeconomic status especially the Blacks, Asians and other indigenous individuals. Another crucial local need in Brent is poor housing which has resulted in low living standards and continued exposure to diseases that are hygiene-related. Older adults with complex health and social care needs require to reside in a safe environment thus reducing their exposure to risks associated with poor living standards.

The most effective strategic plan to meet most of the local state needs of the people living with dementia as one of the critical long term conditions in Brent is the use public programs that lie outside the healthcare system. Introduction of community-based multidisciplinary support can help in meeting most of the local and community needs of the individuals living with complex health issues since care and social services are brought closer to the patients.

Conclusion

Conclusively, long term conditions such as dementia have drastic effects on the health and well-being of the patients with the results being more detrimental on the older adults who are 65 years old and above when compared to the rest of the population. The chronic illness trajectory proposed by Corbin and Strauss shows that cases of patients who have dementia are likely to increase if no effective measures within the health care sector of England are taken to stop this calamity. Numerous barriers prevent patients from engaging with healthcare such as the presence of cultural differences, geographical barriers and stigma. Establishment of effective policies is one of the strategies that can help in eradicating these barriers. Moreover, as discussed in this paper, nurses play a crucial role in providing holistic care to patients with terminal ailments such as dementia. Most of the local community needs are also achieved through collaboration between caregivers in the health care sector and outside the care settings.

Recommendation

Several strategies can be implemented in the effort of enhancing the wellbeing of those patients with long term conditions such as dementia and comorbidity. For instance, the government can introduce new legal frameworks that can help in transforming the health care sector in England in such a way that it facilitates patient-centred care. Secondly, integrating the social and health care services can assist in meeting the various complex needs of patients diagnosed with complex health issues. Thirdly, nurses and caregiver need to introduce educational programs that can help increase the awareness of the public on the importance of self-care, and various ways that patients living with terminal diseases can enhance their self-care and improve their independence level.

 
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