Dementia Navigators Service

Tender description

Surrey County Council (SCC), Surrey Heartlands ICS and Frimley ICS (Surrey Heath, NE Hampshire & Farnham only) are procuring a new contract for the provision of a Dementia Navigators Service. The new contract is anticipated to start no earlier than 1st June 2023 The contract will be a Countywide Service but will be delivered on a local area basis associated with the 11 Boroughs / Districts - Epsom & Ewell, Elmbridge, Guildford, Mole Valley, Runnymede, Spelthorne, Reigate & Banstead, Surrey Heath, Tandridge, Woking, Waverley, This PIN notice will be only used once and is requiring interested parties to confirm their interest in delivering this service Lot 1: Surrey County Council (SCC), Surrey Heartlands ICS and Frimley ICS (Surrey Heath, NE Hampshire & Farnham only) are re-tendering the Dementia Navigators service contract. This service is one of the key elements to delivering the ‘Joint Health and Social Care Dementia Strategy for Surrey 2022 – 2027’ https://www.surreycc.gov.uk/adults/professionals/information-and-resources/commissioning-strategies/dementia-strategy and aims to support people within the community to navigate their dementia journey for themselves and their carers so they can achieve their outcomes. The aim of the service is to provide continuity of specialist support and advice, actively facilitating access and connecting individuals and their carers to services in the community, in a personalised way in order to sustain and improve the quality of life of people with dementia, their carers and family, as and when they need it throughout their dementia journey. Individuals and family members are referred to the Dementia Navigators service following a diagnosis of dementia from a range of sources including: The GP, Memory Clinic, Community Mental Health Service, Action for Carers, as well as individuals or family members being able to self-refer. Indicatively we are seeking a provider that can deliver a service commissioned jointly for 3 years plus 1 plus 1 from 1st June 2023. The Service provider must meet the following objectives:  To signpost people with dementia and their carers to connect to and engage with appropriate support and services within their communities, including making ongoing referrals and supporting people to access these services.  To provide them with information and advice in order to empower them to remain as healthy and independent as possible in their home with choice and control over their lives, linking health and social care support and to encourage them to make plans for their future.  Provide information and support on life planning and preparation for a potential crisis e.g., consideration of legal issues through the Mental Capacity Act 2004 (Power of Attorney). Provide tools and links to help individuals and their carers to prepare and make contingency plans for crisis management and end of life care as appropriate.  Engage with the individual and carer as and when required throughout their dementia journey, responding to their needs from simple 1:1 interventions through to a more complex needs-led service. Providing emotional support either face to face or regular telephone contact, share guidance and facilitate access to appropriate health and social care professionals on appropriate occasions during the progression of the condition and as and when individuals/ carers request this.  Be actively involved and participate in the Integrated Whole System approach, working closely with other partners/organisations in developing innovative service models that respond to the needs of people living with dementia and their carers.  Provide an equitable service across the county, inclusive of people with special characteristics e.g. people with learning disabilities.  Have a strong knowledge of their local area and its services, building relationships proactively with key local networks in order to more effectively signpost, advise and connect people with dementia and their carers to these services. Examples of key partners and local networks include:  Surrey County Council Adult Social Care front line teams, e.g. locality and hospital teams  Local dementia Action Alliance groups and forums  Acute hospitals  GP surgeries  District and borough Community Services Teams  Older People’s Mental Health Teams  Voluntary Sector organisations and other community-based resources e.g. dementia friendly champions  Memory clinics and Surrey and Borders Mental Health Teams  Peer support coordinators  Admiral nurses (where commissioned) This is not an exhaustive list. The electronic Surrey Information Point is also a useful information tool to share with clients; key to connecting individuals and their carers, the Dementia Navigator may include support with accessing these other networks as well as providing information and referrals.  Focus on integrated working and being part of the whole system and being responsive to the whole system demands and capacity, particularly when there are systems pressures.  Awareness and active participation to deliver the local dementia commissioning strategy being part of the Dementia Strategy Action Board and an active member of local Dementia Partnership boards. In addition, each local area is developing an integrated care model that brings together the functions of health and social care to streamline the process for individuals accessing the services. This could be in the form of a physical building with co-located professionals and a range of community services or a virtual integration model to support people to remain healthy and independent and avoid unnecessary hospital admissions. It is expected that the provider will be able to engage with this new way of working in the most appropriate way for the area e.g. working with and sharing specialist knowledge with Multi-Disciplinary Teams (MDT). The provider will ensure that the Dementia Navigators are provided with a programme of ongoing training to include a range of dementia conditions such as young onset (under 65 years) and dementia for people with Learning disabilities to ensure that they have the specialist knowledge appropriate for their role. Volumes of current service: Indicative volumes of the current service delivered is approximately 650 referrals into the service each quarter. This is 2600 per annum. Data Reporting The Reporting for this service is required to demonstrate that it is making a difference to individuals and their families across Surrey. The data must be presented on a Integrated Care System basis (East, Surrey Heartlands, Surrey Heath and North East Hampshire & Farnham), and then be identified by borough / district. The range of information to be provided would include:  The number of new referrals on a quarterly basis  The originating referral source such as – GP practice, Memory Clinic, Acute Hospitals, Community Mental Health Team, Action for Carers, Social Care Teams, Boroughs / Districts, Social Prescribers, Self-referrers.  Re-referrals on a quarterly basis of people returning to the service up to 6 months having previously been closed  Re-referrals on a quarterly basis of people returning to the service between 6 months to 12 months having previously been closed  Re-referrals on a quarterly basis of people returning to the service after 12 months having previously been closed  The total caseload on a quarterly basis as there will be clients that are supported for ongoing periods of time  Telephony data showing volume of calls  The number of clients supported by a Dementia Navigator (not telephony support)  Type of support provided  Cases closed  Outcome for clients  Clients declining support  Demographic Data  Age of Client  Age of Carer if they are the referring party  Gender  Ethnicity This data would be subject to variation as the landscape of health, social care and borough /districts may change in the future. Additionally, there may be the requirement to compile data to meet national health related datasets for example the potential for this service to report against the NHS Community Services Dataset (CSDS) and/or the NHS Mental Health Services Data Set (MHSDS)