Brain Health Service pilot: evaluation - final report

4. Key findings: Brain Health Service implementation and sustainability

In this chapter the evaluation findings focus on the adoption, implementation and maintenance of the Brain Health Service demonstrator site.

Adoption and implementation

The implementation and operation of the Service in Aberdeen have been marked by adaptability and effective collaboration between NHS Grampian and Alzheimer Scotland. As expected with any new service practical challenges arose, some were successfully addressed and others are ongoing.

Service establishment

Stakeholders involved in establishing the Service described extensive co-ordination and liaison to set up this innovative service, specifically embedding an NHS clinic within a third sector organisation. In addition to building alterations and IT arrangements, considerable effort was required to develop referral pathways and protocols and secure access to diagnostic tools like MRI, CT and PET scans. Stakeholders also described delays due to funding uncertainties as budgets were finalised. Overall, interviewees acknowledged that the complexity and effort required were initially underestimated:

“I hadn’t fully anticipated how much work it would take to get this service up and running and how many people we’d need to bring along with us." Stakeholder

Collaboration and communication

Staff and stakeholders praised the strong partnership between NHS Grampian and Alzheimer Scotland recognising its importance in successfully delivering the three-stage service model. Efforts were invested in fostering a positive team dynamic and supportive work environment. Regular operational meetings facilitated reflections on service design and implementation, resulting in improvements such as multiple enhancements to the brain health questionnaire, reinforced guidance on personalised action planning and effective changes for managing bloodwork.

However, ongoing information-sharing constraints remain a source of frustration, particularly impacting on the communication between the Alzheimer Scotland Centre Manager and the clinical staff. The existing protocol restricts a two-way dialogue so the outcome of the Centre Manager referrals cannot be discussed even when the Nurse refers a person back to the Centre Manager for additional support. In this scenario the Centre Manager has to elicit those support needs from the individual rather than being able to talk directly with the Nurse. Whilst the team works within these restrictions it does prevent sharing key information and inhibits continuity of care.

Healthpoint staff enjoyed the time spent at the Resource Centre when providing cover for the Centre Manager but they would welcome greater opportunities to discuss service user outcomes with the wider delivery team as well as collaborating more closely with the Centre Manager so that they can share learning across Stage 1 of the Service.

Nevertheless, despite these constraints, both staff and stakeholders were very positive about the collaborative approach and can-do attitude consistently demonstrated by both organisations.

Referrals and integration with NHS Grampian systems

Improving service integration within NHS Grampian’s existing healthcare systems emerged as a key priority identified by staff and stakeholders. Factors contributing to integration challenges included:

• novelty of the service - initial efforts to establish the service took precedence over relationship-building activities, limiting early engagement with wider NHS colleagues;
• service location: although highly praised for its welcoming, non-clinical setting—encouraging walk-ins and reducing stigma—the clinic's physical separation from NHS Grampian sites hindered recognition and required more concerted effort to make those connections and ensure the clinic complements and supports other services;

“To be honest, it [the clinic] feels a bit like something that exists in parallel rather than in collaboration. We are working in silos rather than as a cohesive system " Stakeholder

• GP engagement: one stakeholder noted fewer-than-expected GP referrals, attributed partly to the busy nature of general practice and indicating a need for ongoing outreach and clear communication regarding the Service existence and referral pathways; and.
• onward referral pathways: while informal connections existed with neurology, older adult psychiatry, and primary care, stakeholders and staff recognised a need for clearer formal pathways. There was also potential for better integration with allied health professionals, including occupational therapists and other clinical areas;

"Because we sit within public health rather than psychiatry, we sometimes struggle to make referrals that would otherwise be straightforward." Staff

However, more recently there has been a notable improvement

“One positive change is that secretaries in the older adult team are now redirecting inappropriate referrals to us instead of rejecting them outright. This means patients who might otherwise fall through the cracks are getting the support they need”. Staff

The staff team felt that with stronger alignment and collaboration with other clinical areas there will be opportunities to liaise more closely with services that are providing care or support to individuals who could access the clinic. Individuals with MCI were a good examples of those who do not meet the threshold for accessing traditional services and would simply be waiting for cognitive deterioration before they could access support.

Staffing and resource management

The staffing arrangements - Healthpoint advisors and the Centre Manager delivering Stage 1 and the nurse and consultant-led Brain Health Clinic worked well and there had been sufficient capacity and flexibility to accommodate fluctuations in demand for the Service.

With the Service managed by non-clinical staff and with limited Consultant capacity, the supervision and support for the Nurse is provided by the NHS Grampian Nurse Consultant for Dementia. Clinical colleagues also provide advice to the manager if clinical issues arise that need their insight. With limited physical space at the Resource Centre a regular managerial on-site presence is restricted. Although these are complicated management arrangements, the team adapted well and continued to work effectively across multiple sites.

A persistent challenge remains the inability to fully utilise the electronic patient record system TrackCare. Although functional for appointments and ordering blood tests, it is not possible for the team to upload patient notes, which means other healthcare professionals do not have access to the comprehensive patient histories and assessments carried out in the clinic. At the time of writing, no solution has been found which creates a frustration and an additional administrative burden for the team.

These challenges have not prevented the Service from operating well but there is recognition of the potential for improving the connections across the team and with other local stakeholders. Nevertheless staff and stakeholders recognised the benefits of such a novel and preventative Service that has supported over a hundred people to address their memory concerns and promote their brain health.

Motivation for accessing the Service

Graham is 59 years old and found out about the Brain Health Service from a friend. He expected the Service to offer a memory assessment and thought that the results would provide a benchmark that could be used to monitor brain health over time.

“My thoughts were, I’d heard from a friend that you can take a test. I thought that was a great idea, I’d like that repeated every year so you have a trend of your brain health year on year.”

Experience of the Service

Having read a newspaper article about brain health, Graham was familiar with the risk factors prior to accessing the Service. He chose to walk into the Resource Centre where he then met with the Centre Manager. During the conversation about brain health, the actions he could take to mitigate against some of those risks were identified. Graham thought that a memory assessment would provide the motivation needed to make changes to his lifestyle:

“If you look at your overall health, you run a mile and then improve your time a year later, you’ve got a template of where you are with your physical health. You can train that, if it goes low, then you think you need to do something about it, that is biggest motivator to do with physical health. With brain health, I was looking for something similar. That would be the biggest motivator to change the 19 inputs.” However, Graham wasn’t referred to the clinic for an assessment and recognised that, without a memory concern, a referral wasn’t a good use of NHS resources. He instead called for some form of assessment to be made available online so that “everyone could do one.”

Behaviour change

Despite not receiving the information he felt he needed to take action, Graham had recently bought a blood pressure monitor and was going to try to reduce saturated fat within his diet.

Graham, 59-year-old male

Alignment with the service model

The Service in Aberdeen closely aligned with the original model presented in the Brain Health Services: Recommendations for Clinical Practice. The service effectively adopted the recommended structured, three-stage approach, providing initial public-facing awareness and advice (Stage 1), followed by detailed clinical assessments and interventions through nurse and consultant-led teams (stages 2 and 3). The ongoing commitment to community outreach and public education on brain health and personalised assessments of risk are consistent with the original model's principles.

Key aspects, such as the triage processes, patient-centred approach, and tailored support plans, have been implemented. Additionally, the community-based, stigma-reducing settings aligned with the recommended practice of delivering accessible, supportive environments. While operational aspects, such as better integration with local NHS systems and information sharing require ongoing improvements, the service's overall implementation fulfils the goals and strategic vision outlined in the original recommendations.

The stakeholders involved in the early design of the Service highlighted how closely the current operation reflected the intended preventive and educational emphasis within the model which has been successfully translated into practical service delivery through the unique partnership between NHS Grampain and Alzheimer Scotland.

Motivation for accessing the Service

Joe, aged 62, lives in Aberdeenshire and found out about the Brain Health Service at a wellbeing event in the city. Because he had a family history of dementia, he decided to speak to the team at the event and then follow it up with a visit to the Resource Centre. Joe didn’t think he would have accessed the service without this initial contact:

“Probably wouldn’t have gone along to King Street if they hadn’t been there [at the outreach event]. I don’t think it would have been a natural move to make.”

Experience of the Service

Joe expected it to be an information gathering visit but, because he felt at ease, went onto have a broader discussion about his lifestyle and his risk factors with the Centre Manager.

“For the first time ever, I think I was in what I deemed a safe place and enabled me to open up. It became a much broader conversation… It’s the space and the individual you’re dealing with. It’s obviously a skill, there’s not a lot of prompting there. Encouraged me to open up and be honest about where I was at and from that, we then moved into possible solutions or approaches we could try to help with some of the other stuff.”

Behaviour change

What was described as an “informal action plan” which focused primarily on alcohol reduction was put in place. Joe has since reviewed his progress in several follow up visits to the Service and felt that the support he’s received has motivated him to make changes:

“Most of what I’ve done has been self-initiated and motivated but only because *[Centre Manager] facilitated it and has supported and encouraged me to do it. I think it also gives me another reason to persevere because… I would be letting myself down as well as her if I didn’t do the actions.”

Joe is maintaining his healthier lifestyle and feels like he’s now “in a far better place” because of it. As well as having the action plan in place he was also encouraged to visit his GP if wanted to have a more formal memory test. This took place with his GP and no issues were identified.

Joe, 62-year-old male

Maintenance and sustainability

Ensuring continuity of the Service beyond its initial test site phase was a priority for most stakeholders, who highlighted the importance of stable, long-term funding, sufficient staff capacity, and ongoing national commitment. There was confidence that the Stage 1 could be maintained within the public health function of Healthpoint without substantial additional investment, but the same staff members emphasised that the clinical components of the Service needed to be more closely aligned with NHS Grampian clinical areas in order to solidify the Service’s viability and attract a financial commitment so that the long term benefits of the Service could be realised.

The stakeholders with a detailed understanding of brain health recognised the essential role that the Service and other brain health clinics will play in the near future, highlighting several critical reasons:

• advancements in early detection and therapeutics: the emerging therapeutic options and biomarker technologies are significantly improving the early detection of cognitive impairments and dementia-related conditions and so as these diagnostic capabilities become more sophisticated, the demand for dedicated brain health services to provide early intervention, ongoing support, and preventative strategies will inevitably rise;
• preventative health emphasis: with current healthcare models predominantly offering support only after a dementia diagnosis is confirmed, it is leaving individuals with MCI or early symptoms with limited resources or structured support and brain health clinics address this gap by providing targeted, preventative interventions aimed at slowing or reducing the progression to dementia;
• integration with public health initiatives: there is a growing recognition of the value of integrating brain health services within broader public health frameworks, and as Stage 1 of the Service has shown, there are indications it can promote widespread behavioural change through public education, early intervention strategies, and structured action plans, which could significantly reduce the overall burden of dementia on healthcare systems; and
• cost-effectiveness: although the evaluation did not consider the resource allocation, stakeholders felt that the early identification of cognitive impairment through brain health clinics should allow for more effective resources and use of healthcare professionals' skills. In their view, as new medications and treatments emerge having established pathways for early detection and management should prove cost-effective and clinically beneficial.

Service users and survey respondents echoed some of these sentiments, stressing the importance of accessibility to maximise service reach and effectiveness:

"Excellent service, just fear it is not reaching the massive target audience and promoting early intervention to the extent it could." Survey respondent

“I just hope that going forward that funding is put in place to maintain it. It’s been hugely beneficial and probably helps avoid more complications and serious issues down the line. It’s a great intervention and support tool.” Service user

Scalability

Stakeholders were broadly optimistic about the scalability of components of the model, identifying its clear potential for expansion and replication in other areas. However, they acknowledged key elements like an extensive planning phase, prolonged outreach activities with the public awareness and local partners to ensure visibility and support integration with existing healthcare infrastructure.

"Needs a significant investment in promotion of the service and engagement in public settings..." Survey respondent

Considerations were highlighted about the practicalities of extending a model of this type, such as managing staffing capacity, resource allocation, and the optimal placement of the service within health or third sector structures. Stakeholders advised careful planning based on regional demographics and healthcare demand to ensure effective and sustainable implementation. They also recognised the challenge of funding a service focused on prevention during a tight fiscal period.

Stakeholders valued the upstream and proactive role that public health played within stage 1 of the Service, it aligned well with its public education and health promotion function. However, these stakeholders and some staff felt that the clinical element of the service should sit within existing clinical departments like psychiatry or neurology so that the Service could be embedded in established structures which would enhance its sustainability and acceptance. They suggested that the Aberdeen Service could still be based in a third sector organisation, but the management of the clinic could sit within a clinical department.

“If the Service is to continue, I think it would make sense for the clinical aspect to be based within an existing NHS service—such as mental health or another part of primary care.” Stakeholder

Stakeholders and staff repeatedly expressed concerns about sustainability, particularly highlighting the challenges associated with funding uncertainties and the lack of long-term funding commitments and strategic planning for preventative services which constrained innovation and longer-term development of models like the Brain Health Service.

Adaptability to local contexts

Despite this, stakeholders were optimistic that the model could be rolled out to other areas. They recognised the importance of adaptability to local contexts as a cornerstone of scalability. They emphasised that there should not be a rigid, one-size-fits-all approach but rather an adaptable model responsive to local resources, needs, and existing healthcare infrastructure. Several stakeholders advocated for testing various service models in diverse settings to learn from different approaches and maximise effectiveness:

“Didn’t think there was a single model...each area should work within the envelope of resources available to them.”

Some stakeholders expressed their aspiration for a Scotland wide network of brain health services, tailored to local need and with the flexibility to adapt as the dementia prevention innovations develop. They saw the Aberdeen model as a demonstrator as to how this could be done and what could be done differently.

As the evidence becomes clearer about how sustained, personalised interventions, such as those provided by brain health services can facilitate lifestyle adjustments and health improvements, some stakeholders were confident that dedicated brain health clinics will become essential to meet the increasing demand for preventative services providing comprehensive support to individuals experiencing early or mild cognitive concerns.