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Waterton Park Hotel, Wakefield, WF2 6PW Wednesday 8th March 2017
Yorkshire & the Humber Memory Service Network
Chris North (Joint Chair) Dr Tolulope Olusoga (Joint Chair)
Joint Clinical Advisor (Dementia Diagnosis & Treatment Services)
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@YHSCN_MHDN #yhdementia
Housekeeping:
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Update of evidence based treatment pathway
Penny Kirk – Quality Improvement Manager & Chris North – Joint Clinical Advisor (Dementia
Diagnosis & Treatment Services) YH Dementia Clinical Network
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Evidence-based treatment pathway
The pathway is monitored using two pathway standards: • The first recognises the need to standardise
timeliness of diagnosis, and access to NICE-recommended treatment when needed (Referral to treatment).
• The second focuses on the need for ongoing access to good quality post-diagnostic support once a diagnosis has been made.
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Standard 1 - Referral to treatment • By 2020, 85% of people with suspected dementia
referred to a memory service receive a diagnosis and start treatment within 6 weeks
• Clock starts when the referral is received. • Starting treatment means:
• the person has met with their named care coordinator coordinator of care AND
• an initial care plan of NICE-recommended care for dementia has been agreed
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• It will not be possible (or advisable) for all people to be diagnosed within 6 weeks.
Examples cited: • The person may be physically unwell • The person may choose to postpone their clinic appointment • A complex diagnosis involving multiple investigations and
assessments may need to be carried out. • If the recommended response time is exceeded, it is important
that the reasons for the delay are clearly recorded in all cases. • Records should be monitored and managed jointly by the
commissioner and provider, and improvements should be made where possible.
Exceptions
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Standard 2 - Post-diagnostic support • Every person living with dementia receives ongoing,
NICE-recommended, post-diagnostic support • The person’s support needs are recorded in an initial
care plan. • This care plan is reviewed at least once within 12
months of when it is first agreed, and every 12 months thereafter, as the person’s needs dictate.
• Revisions are jointly developed and agreed with the person living with dementia (and, if applicable, their carer).
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• MSNAP will be introducing a self-assessment process for the new EBTP guidance.
• Participation will be mandatory and free at least for the first year.
• Each service will receive a report against the standards. • Monitor Year-on-Year progress • Self assessment results will be separate to accreditation
but will use self-assessment towards accreditation where appropriate
• MSNAP standards will be revised to reflect new standards (once published)
Assessment
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• Development being led by HEE • Draft tool circulated for comments by 10th January • Currently being revised in light of feedback • Revised version expected within the next fortnight
Workforce planning tool
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• Published 2nd March • https://www.england.nhs.uk/mental-health/resources/dementia/ • Care planning is a crucial element in delivering improved care for all people
living with dementia, and supporting their families and carers. This has been brought into sharp focus through the CCG Improvement and Assessment Framework which includes indicators for dementia diagnosis and post diagnostic support.
• The information provided in this resource document highlights the key characteristics of a person-centred dementia care plan and is aimed at primary care and commissioners who provide care plan reviews as part of the Quality Outcomes Framework (QOF) incentive scheme in primary care.
• This resource document covers: • The components which constitute the minimum information to be
included in a good care plan. • Examples of dementia care plans that are already being used at a local
level.
Dementia: Good Care Planning
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• Outcomes of a care plan are a key measure of its
efficacy and assessing this is important. The following three outcome tools are recommended for routine use in memory assessment services:
• o Health of Nations Outcome Scale-65 (HoNOS-65); • o Friends and Family Test (FFT); and • o Patient Experience Questionnaire (MOPE-PEQ).
Outcomes
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BAP Guidelines
• British Association for Psychopharmacology- guidelines for prescribing for dementia
• https://www.bap.org.uk/pdfs/BAP_Guidelines-AntiDementia.pdf
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Nicola Phillis Quality Improvement Lead
Y&H Clinical Networks
Revisit of SWOT analysis, themes identified and what we know about
Y&H (findings from the online audit)
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• Last meeting (1st Nov 16) the Evidence Based Treatment Pathway was introduced
• Two standards: Referral to treatment (6 weeks) Post diagnostic support
• SWOT analysis carried out between two groups • Themes identified
SWOT analysis
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Referral to treatment Strengths Weakness
• Reducing waiting time to receive a diagnosis might reduce anxiety for service users and carers.
• Lots of things outside the control of memory services e.g.
• CT access • Priorities of other services • Receiving the right information on the referral
form and chasing up missing information.
Opportunities Threats • To work with others in different areas. • To explore changing working practices, structures
and models. • To explore existing skill mix and potential new roles
for advance nurse practitioners. • Move away from medical model –empowering for
nurses & AHPs. • Empowering existing staff and non medical
prescribers. • Direct access to CT scan (Cleethorpes) – patient can
turn up any time during that time.
• Receiving a diagnosis of dementia might make some patients feel rushed as the time frame is too short for them.
• Current staff capacity. • Primary care is not always referring. • Unsure of how will this apply to primary care based
services? • Numbers of people coming through memory services
is increasing which can lead to delays in reporting.
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Post Diagnostic Support Strengths Weakness
• Named contacts in place for 1st 12 months • Opportunity for consistency in what’s delivered and
equitable access • Clarity and relevance to need • Nobody should be missed – enables to • streamline someone’s journey and help to understand
organisational complexity • Already have models in place to identify a named
contact from other sectors • Relevant to need • Pathway is clear
• How can we make sure that people who are diagnosed via other routes still get access to PDS?
• How can we support disengaged patients and carers? • Services are starting from different points • Who will coordinate PDS? Confusion for client and
carer on what produces what and coordinates • There might be duplication with 3rd sector provision • Pathway can be become automated • When something goes wrong does this come back
into the service? • Lack of in-home support • BAME access to services and PDS. • Sharing of information across agencies.
Opportunities Threats • Could broaden scope of what is offered. • Help to identify black holes • Using guidance to drive joint working across different
organisations and sectors • Data will help to identify areas of inefficiency, inequity • To commission a post diagnostic service • Collaboration • Address carers needs as a result of assessment • Opportunities to engage with other providers • To streamline patients journey • Understanding organisational complexity
• Fidelity, maintaining standards. Possible alienation • Who’s funding and monitoring PDS? Who owns the
care plan? How is it determined who facilitates and manages the review?
• IT challenges of care coordination • Sharing information across different agencies • Cuts to social care budgets – social support services
are being cut, PBs, PHBs are challenging to arrange • What happens to named coordinator after 12 months • Cuts to social care / person budgets /direct payments • Covering everything from everyone’s points of view
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• Following the last meeting on 1st Nov 2017 • Aim to understand the current picture ahead of Evidence Based
Treatment Pathway Launch • Audit designed by clinical network with input from our clinical
advisors • Administered using survey monkey and email (with regular albeit
annoying chasers- sorry)
• Difficult exercise: • Issues with recording systems. • Recent changes to recording of diagnosis information • Time restrictions exploring qualitative data
Findings from Y&H mini audit
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How many referrals do you receive each year? • 12 responses out of 20 • Range 520- 3331
0
500
1000
1500
2000
2500
3000
3500
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• 12 responses • Range from 0 – 50%
What percentage of referrals are turned down?
2
7 10
0 0
50
2
6
0 2 2
5
0
10
20
30
40
50
60
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• Inappropriate or incomplete referrals • Cognitive Screening from GP is a normal range e.g. 6Cit below 8 • Dementia screening not completed • Missing bloods/medical history on referrals • Referral is of poor quality making triage difficult • Other things not ruled out, e.g. alcohol or drugs or not meeting service criteria • Age inappropriate referrals
• Physical health
• Poor physical health such as renal failure, hyponatremia; a period of physical stability advised prior to assessment
• New diagnosis of brain tumours. • Rapid onset of memory problems following a road traffic accident
• Other dependences • Need to wait for CT head or blood result • Other mental or physical issues needing further input from CMHT • Clients are housebound
• Patient decisions
• Patients not felt appropriate due to their physical health • Patient/carers declining input either because they did not feel their memory was a problem or because
they did not want assessment or treatment • Patients who have moved out of area before an assessment could be completed
Main reasons why referrals are turned down:
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• 7 responses
After receiving a referral, what percentage of patients currently receive a diagnosis within…
0
10
20
30
40
50
60
70
80
90
100
1 - 6 weeks
7 - 12 weeks
13 - 18 weeks
19 plus weeks
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• 6 responses • Comments received that the data was unavailable
What is the percentage breakdown of diagnosis in your memory service?
0
10
20
30
40
50
60
Mild cognitiveimpairment
Alzheimer’s disease Vascular dementia Mixed typedementia
Dementia with lewybodies
Fronto- Temporaldementia
Other
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• 6 responses • Range from 50 – 100%
What percentage of your patients require a CT scan?
Name of service Percentage requiring CT scan Wait in weeks
92.50% 3 weeks
100% head scan, approx 10% MRI
6 – 7 weeks
50% 8 weeks
Work ongoing to determine this 2 – 8 weeks
90% 6 – 8 weeks
100% 3 weeks
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DNA rates Name of service % of new patients that
DNA % of follow ups that DNA
16% 14%
Data not available (DNA policy in place, memory services duty worker follows up DNA's with a phone call)
Memory service not commissioned to follow up once a diagnosis and treatment is complete. They are discharged back to their G.P who undertakes an annual review.
17% 18%
1.4% .
14% 14%
20% 10%
Date
Findings from the London Memory Service Network
March 2017
Dr Jeremy Isaacs Dementia Clinical Network Effective Diagnosis Lead Consultant Neurologist St George's University Hospitals NHS Foundation Trust Laura Cook Quality Improvement Manager Dementia Clinical Network, NHS England London Region
26
Memory Service Network
o The London Memory Assessment Network was formed in October 2014
The objective of the network is to:
• Share best practice in clinical care and service design. • Provide CPD / learning opportunities that are not readily
available elsewhere. • Reduce variation in care and improve quality
o Quarterly network meetings o London wide clinical audit was completed in 2015 and data is
currently being analysed for the second round of the audit
27
Pathway Project
• Letter sent to all memory service clinical leads and service managers in November 16
• Invitation for a one hour meeting to explore: Patient pathways Barriers to reducing waiting times Any local waiting time solutions
• Also discussed: Integration with Geriatric Medicine and Neurology Join Dementia Research
• Semi-structured meeting schedule
Triage Initial Assessment Investigations 2nd
Appointment
28
Pathway Project
• Meetings completed with 11 services in London - covering 13 CCGs and 8 Mental Health Trusts.
• Further meetings planned to end of May
Pathway reviewed from referral to diagnosis and initiation of treatment plan
29
Overall Picture
• Some patients in some services are receiving a diagnosis within 6 weeks
• All services currently estimate an average time to diagnosis of over 6 weeks from referral
• In some services patients are waiting up to 6 months for a diagnosis
• Services pathways are hugely varied
30
Triage
• Referrals mainly come from GP’s • One service accepts self referrals. Others direct patients
through the GP
• In general, referrals are not rejected due to missing information • Memory services have to proactively chase information. • One service has access to GP system • All services have referral forms, but often receive letters. • Received via email, fax and post • What happens when a referral reaches a service is very
varied……
31
Triage Process Varies
Clinician
• Daily triage • Refer for scan • Allocation
Admin Staff
• Liaise with patient and carer and book into fixed assessment slots
CMHT
• Screen all referrals • Liaise with patient
and NOK
Memory Service
• Weekly allocation meeting
Clinician
• Staff book appointments in their diary and liaise with patient / NOK
32
Initial Assessment – Different Practice
Clinic
Home
Nurse
OT Psychologist
Consultant
Where
Who
Diagnosis Made
1-2 Hrs
Scan Clinical
Confidence
Nurse prescribers
SW SpR Jnr Dr
33
Patient Discussions
• Services had different mechanisms to discuss patients
Weekly MDT
Informal Discussions
Formal Supervisio
n
Supervision in Clinic
Floating consultant in clinic giving
diagnostic support
34
Imaging – Questions Raised
• Which patients should have a scan?
• Default MRI or CT
• When requested -at screening OR after initial assessment
• Reporting -Who reports / Quality? - Access to PACS
• Contract -Is there a contract? - Use of private providers -Waiting times 2-8 weeks
• DNA avoidance …….
35
Service initiatives to avoid scan DNAs
• Sending patients a letter explaining that the memory service had requested a scan
• Memory Service administration team reminding patients
• Named coordinator - keeps a clear record of appointments and reports, and can facilitate patients attending
• Some imaging departments chase patients if they haven’t confirmed their appointment
• A ‘family protocol’ where the memory service indicate if a imaging department will need to contact a relative.
• Outreach worker from CMHT can take patients to their appointment
36
Neuropsychology
• The need for neuropsychology varied from 5% in some services to 25%
• Services awaiting up to 3 months for a report Need to consider • Availability • Integration with team • Shorter assessments – specific diagnostic question • Which patients definitely need diagnostic neuropsychological
assessment
37
2nd Appointment
• Default is clinic appointment. Except one service – all home visits
• Diagnosis – Professional who completed initial assessment OR - Consultant • General consensus that 2nd appointment is still valuable if a
patient is given diagnosis at initial assessment • Further follow ups – need to consider impact on workforce
38
Other Service Initiatives
GPs diagnosing in care homes
Discussing under 65
referrals with GP
CPNs trained to
assist assessment
s
OT home assessmen
t if concerns in clinic
Home visit only if
housebound
Waiting list initiatives – note high DNA on Saturday
39
In summary
Digital • Online diaries with slots • Access to scans and
reports
Workforce • Optimal use of staff skill set • Which staff can diagnose
autonomously?
Triage • Think ‘lean’
Home visit vs Clinic appointment
Scanning • Contracts • DNA avoidance
Under 65 • Bespoke pathway required
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Questions and Group discussions
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Yorkshire and the Humber Memory Service Network
Time for a break?
Advanced Nurse Practitioner role in Wakefield Memory Service Angela Depledge [email protected]
Content • Background to development of Advanced Nurse
Practitioner (ANP) role in Wakefield Memory Service
• Trust Transformation plan for Older People’s Services
• New standardised job description for ANP role • Governance document • Broader development of ANP roles in other
services and teams in the Trust
Background (in the service) • Speed up access to ‘non-complex’ dementia
diagnosis • Utilise the skills of experienced memory nurse staff
effectively • Maintain continuity of contact with a known
healthcare professional • Non-Medical Prescribing well established • Nurse diagnosis well established in the service via
Nurse Consultant role
• Transformation of the dementia assessment pathway in the Trust (clear evidence based pathway)
• Nursing strategy for the Trust, modernising nursing roles and career paths (standardising job titles, role content etc., values based job descriptions)
• Delivering cost effective services, reducing reliance on agency medical staff.
• Utilising Consultant level staff for more complex presentations
Broader Background (in the Trust)
• Proposal discussed and agreed with members of the Trust Board ( Nursing & Governance lead, Medical Director). Support from lead Clinicians in each locality.
• Implementation group set up to produce Clinical Governance document, new JD’s & identify an appropriate post-graduate course to deliver required competencies
• Involved Business Managers, Practice Governance Coach, Clinical & Managerial leads, professional leads and Human Resources
Process for developing the posts
Outcomes
• Post graduate certificate in dementia for health care professionals with a special interest in dementia
• Governance document and referral pathway and criteria in place
• Job descriptions devised and implemented
s
Outcomes (2) • Agreed person specific for interested applicants
(significant experience as Band 6 or 7 Memory Nurse, independent prescriber, previous successful degree level study).
• Banding on successful completion agreed to link with academic level (Band 7)
• Clear preceptorship & supervisory process on successful completion of the course
Structure of the course • Two modules: Assessment and diagnosis of dementia. Pharmacological and Psychosocial support for people with dementia . • Distance learning & flexible. Support from the Trust
& HEE funding
• Assessment of clinical competencies
My experience of the course • In-depth learning experience • Able to really apply this to my practice with people
experiencing dementia and their carers • Difficult to juggle with a busy clinical role • Essential support of all my colleagues within the
team • An on-going learning and development process,
ready for the challenges ahead
Broader Context in the Trust
• ANP role in memory services has demonstrated how to utilise service transformation and opportunities to modernise nursing roles and careers to achieve improved quality and cost effectiveness in service delivery.
• Research Bid prepared in collaboration with Huddersfield university to evaluate these roles.
Harrogate , Wetherby and Rural District Memory Services
Dr Tolu Olusoga
Consultant Psychiatrist and Clinical Director, MHSOP (NY)
March 2017
Background Harrogate - Part of TEWV NHS Foundation Trust
Provision of mental health, learning disability and substance misuse services to a population of 1.6 million people living in County Durham, Darlington, the Tees Valley, Scarborough, Ryedale, Whitby, Hambleton and Richmondshire and Harrogate – an area covering over 3,600 square miles.
We have over 6,000 staff working out of around170 sites, and an annual income of £300m.
We are commissioned by and work in partnership with 8 local authorities, 9 CCG’s
Trust footprint involves 3 STP areas.
The Area We Cover Key:
11: Chester-le-Street
12: Stockton
13: Middlesbrough
14: Wetherby Town
Office of National Statistics (2011) 14
Harrogate Memory Services Includes Harrogate, Wetherby, Ripon and surrounding
areas
Population - 34,000 older people.
Across 2 CCGs
Service Composition 0.5WTE Consultant Psychiatrist
0.5 WTE Team Manager
1 WTE ANP (recently commenced in post)
4 WTE B6
0.8 WTE B5
1 WTE B3 HCA
1 WTE B3 Admin
Problem Lengthy waits for assessments – 6months.
Inconsistency in care pathway.
Lack of capacity
Recruitment challenges
Retirements
DNAs
Solution Service improvement using TEWV -QIS methodology
(RPIW) started in 2014.
Further expanded in January 2016.
Objective -Eliminate waste, improve patient experience and outcomes within existing resources
Addressed capacity issues with CCG through shared care
Addressed assessment pathway
One Stop Assessments (70%) Referral received from GP with baseline blood
investigations
Nurses contact patient by phone to consent for CT head.
CT head requested and results received within 3weeks
Appointment offered to patient by phone with formal letter following.
Patient attends with significant other/friend
Initial assessment completed by nurses (60minutes) includes history, PMH, FSH, Childhood Education and employment history, Allergy history , blood pressure, pulse, height and weight, Addenbrookes, Bristols ADL +/- GDS if indicated.
MDT carry out Diagnostic Formulation (with the doctor/consultant in attendance) (15mins)
Doctor+ Nurse (MDT) clarifies presentation with patient and carer, discuss diagnosis, treatment options and clinic letter dictated and all electronic records completed (60mins).
Driving issues and DVLA responsibilities discussed.
Information given with leaflet about diagnosis, medication, DVLA questionnaire and POA.
Appointment made with nurse for post diagnostic support.
Postdiagnostic appointment occurs 3 weeks after diagnosis.
Further discussion about side effects, carer stress and support
Discussion about CST, Living well with dementia groups
Discussion about role of research and interest –JDR
Signposting to Alzheimer’s society or dementia forward
Post-Titration Appointment Patients are monitored monthly for 3 months or until
titration is complete and stable and care transferred to GP as per shared care after CST where indicated.
2 Step Assessments (30%) For patients that are complex requiring further
investigations – PET scan, DAT scan, Neuropsychometrics or clear evidence of delirium.
These patients have an initial assessments by the memory nurses and return to see the doctor once all the necessary investigations are completed and results received.
Nurses are experienced and are supported using protocols to refer to psychology and will discuss with doctor re further investigations.
Re-referrals Patients have a quick route back in.
Notify GP of concerns re behavioural changes/aggression or agitation/carer strain
GP practice admin use agreed template(5 basic questions) and transfer the information to memory clinic admin by phone.
Memory Service nurses accept referral and make contact with patient within 3-4weeks (aiming to get this to 2 weeks).
Patient gets a review appointment with subsequent case discussion at MDT and plan agreed.
Memory nurse facilitate plan which may include a further appointment with a doctor if required, transfer to CMHT if likely to require extensive involvement or short term piece of work.
Workload 496 patients were seen from Jan-Dec 2016 for
diagnosis using this approach (Of these about 200 had 1 stop assessments). Since January 2017, 70% of all patients seen are seen via 1stop pathway.
250 patients were seen from Jan-Dec 2016 for reviews.
Challenges Ongoing need to do more with less (Financial)
Older workforce
Changing technology and slow adaptation
Administrative burden – electronic record accounting for significant amount of staff time (60%-70%).
IT issues
PBR
Next Steps ANP being trained and supported to be able to deliver
simple diagnosis with consultant backup support.
B6 improving their competence at managing reviews.
ANP taking on reviews and supporting B6 nurses freeing up consultant to do more complex work including Young Onset Dementia and more active participation in Dementia Research.
More use of shared Clinical Leadership model (Team Manager, Psychologist and Consultant) to support the team.
Discussion & Questions
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Online Memory Service Forum
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On Line Discussion Forum
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On Line Discussion
Forum
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On Line Discussion Forum Notifications
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On Line Discussion Forum Notifications
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Group work and future planning
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• Regional dementia leads meeting 14th March • Mainly aimed at commissioners in Y&H • Introducing the EBTP • Is there anything you would like the CN to raise?
• Future joint RDLs and MS meeting in September
• What would you like us to include?
Regional dementia leads
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• Four meetings per year • Attendance by
• Memory service managers/leads • Lead consultant psychiatrists
• Purpose • To provide co-ordination and direction to support accelerated
implementation of the EBTP in Y&H • To supporting the delivery of high quality care for people with
dementia and their carers • Promote and accelerate the adoption of good and innovative
practice across Y&H • Review information to identify: issues and challenges within
the system • Act as an expert advisory group • Other ?
Terms of reference
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Any Other Business
• Date and time of next meeting 1st June AM or PM • British Assoc for Psychopharmacology-guidelines for
prescribing for dementia • Good care planning guide
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Contents
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