The Fife Dementia Strategy: 2010 – 2020 - The Knowledge Network

development, have gone some way in improving communication across
services; however they continue face difficulties in ensuring continuity and
consistency.
In order to ensure clinicians and care providers have the appropriate
information to provide care and that information is being shared efficiently and
effectively, it is recommended that a virtual care management system is
created for people with a diagnosis of dementia in Fife. The system will be
developed using existing tools and technologies, and will be appropriately
accessible by all clinicians and care providers who diagnose or are involved in
the care of people with dementia. Such systems have been successful in
caring for people with diabetes in Fife and have functioned to:
• Facilitate information sharing.
• Prevent omission or duplication of services
• Allow audit of the service
• Provide a call/recall system
• Help identify unmet need
• Link with national screening programmes for associated conditions.
The virtual system will explore linking the SSA, with the GP Register, NHS
OASIS system, and the new electronic Palliative Care Summary (ePCS).
Individuals with dementia in Fife will be identified through existing general
practice dementia registers and OASIS or as they receive a new diagnosis.
People will be given the opportunity to opt into the sharing system in line with
the Mental Incapacity Act.
Achieving the above will require not only organisational commitment and IT
expertise, but will also mean that the SSA is re-worked in partnership with
frontline health and social care workers and using the principles of good
practice in dementia care. Financial investment will be required; however the
success of the system will underpin the delivery of seamless clinical and
social care services, and will play a key in future service and resource
planning. It will also play an important part in managing the improvement to
services made as a result of this Strategy and can be used to assist providers
to follow appropriate diagnostic and care guidelines.
This system may also be used to develop an active research programme in
Fife whereby people have access to relevant and up to date research
information and are given the opportunity to participate in clinical trials and
research of their choice.
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