Introduction and background
In June 2010, the Scottish Government launched Scotland's first National Dementia Strategy. In 2011, NHS Education for Scotland (NES) and the Scottish Social Services Council (SSSC) developed Promoting Excellence: a framework for all health and social services staff working with people with dementia, their families and carers to support the strategy and implementation of The Standards of Care for Dementia in Scotland (2011).
Since then, the Scottish Government has published two further dementia strategies, the most recent covering the years 2017 to 2020. Consultation on a fourth strategy was planned for the start of 2020 before the onset of COVID–19. The Scottish Government will now publish a National COVID–19 Dementia Transition and Resilience Plan to respond to the on-going challenges around the impact of the pandemic on people with dementia and to continue to build on and extend national action in the 2017–2020 strategy, including in the key area of post-diagnostic support.
On-going implementation of Promoting Excellence will remain a key part of our national work on dementia, including in response to the current public health challenge, and is complemented by the national dementia AHP framework, Connecting People, Connecting Support.
The wider national policy context has also changed and progressed since 2011, including the integration of health and social care, the roll out of self-directed support and the legislation which expands support and entitlements for carers.
The Promoting Excellence framework reflects the actions, priorities and commitments of the dementia strategies and on-going national activity on dementia. NES and the SSSC have been active since 2011 in supporting the four levels of the framework in practice, including the development of:
- core educational resources
- training programmes; and
- developing leaders and infrastructures to support implementation.
The 2011 Promoting Excellence framework was ground-breaking as Scotland's first national workforce development framework. It set high aims for the care and support of people with dementia, their families and carers.
This 2021 version reflects progress made since 2011, such as:
- new research on preventing dementia, new ways to support people across their dementia journey (including the Scottish Government's national commitment on post-diagnostic support effective since 2013), and what works best for people with dementia, their families and carers;
- new laws, including the Carer's Rights (Scotland) Act; and
- new human rights-based Standards for Health and Social Care.
The purpose and structure of the 2021 version of the framework has not been changed. What has changed are some of the knowledge and skills statements in the framework levels and domains sections.
The purpose of the framework
The framework sets out the knowledge and skills all health and social care staff should achieve in their roles in supporting people with dementia, their families and carers. It works alongside other standards and frameworks, such as the NHS Knowledge and Skills Framework, the Social Services Continuous Learning Framework and the National Occupational Standards for Health and Social Care. The framework also has relevance and applicability to other sectors, such as housing.
The Promoting Excellence framework:
- adds to these existing frameworks;
- applies to all health and social care staff who have contact with, and provide support, care, treatment and services for, people living with dementia, their families and carers;
- is future-focused, meaning it is not just a description of what we do now — it is also what we aspire to do in the future to support the changes outlined in Scotland's national dementia strategies; and
- sets out the knowledge and skills needed for new ways of working for all health and social care staff to help people with dementia, their families and carers to maximise their rights, choices, and health and wellbeing at all stages of their own dementia journey.
The evidence and principles for the framework
The original 2011 framework was based on a number of activities, including:
- gathering evidence, best practice guidance and reviews of research and reports;
- reviewing competency frameworks;
- making links with wider UK dementia work programmes;
- consulting with a wide range of people with an interest in care and support for people with dementia, their families and carers.
This 2021 version has used similar activities. Experts, including people living with dementia, their families and carers, have been involved in developing this version of the framework. We acknowledge their contribution in Appendix ll.
The most important thing is that the framework is based on the values and principles that people with dementia, their families and carers have said are most important to them.
The framework highlights and supports the primacy of people's rights. These are based on The Charter of Rights for People with Dementia and their Carers in Scotland and The Standards of Care for Dementia in Scotland. The key resources used to develop the framework are shown in Appendix I.
How the framework should be used
The framework should be used at a personal, service provider and organisational level in several ways, and for a range of purposes. This will be achieved:
- By individual staff members (in conjunction with their appropriate generic and/or professional frameworks and guidance) to help them fully understand the values base and knowledge and skills expected of them to fulfil their responsibilities in delivering excellence in dementia care, support and treatment.
- By individual staff members, alongside their managers/supervisors, to identify and explore their strengths and any gaps in knowledge and skills in relation to the role they are performing. It will allow both to identify and take action to address any development needs to deliver the aspirations set out in this framework.
- By providers of services commissioned by health or social care to ensure people with dementia receive care, treatment and support of the highest quality that meets the standards.
- By organisations to ensure staff have the necessary knowledge and skills to meet the needs of people with dementia, their families and carers, and to plan staff development activities to reflect the aspirations set out in the framework.
- By organisations to identify any staff development needs to support delivery of the Standards of Care for Dementia in Scotland.
- By education and training providers to inform the content of the education and training they provide and shape the design and delivery of future-focussed vocational and professional undergraduate and post-graduate education and training.
- By people with dementia, their families and carers to ensure they are aware of and can exercise their rights and entitlements for excellence in the support, care and treatment they should expect to receive.
The structure of the framework
Levels of knowledge and skills
Each level sets the specific knowledge and skills specific staff need based on their role rather than their position in the organisation, or their profession.
The Dementia Informed Practice Level provides the baseline knowledge and skills required by all staff working in health and social care settings, including in a person's own home.
The Dementia Skilled Practice Level describes the knowledge and skills required by all staff who have direct and/or substantial contact with people with dementia, their families and carers.
The Enhanced Dementia Practice Level outlines the knowledge and skills required by health and social care staff who have more regular and intense contact with people with dementia, provide specific interventions, and/or direct and co-ordinate care and services for people with dementia. The knowledge and skills outlined at this level become increasingly role and context specific.
The Expertise in Dementia Practice Level outlines the knowledge and skills required for health and social care staff who, through their role and practice setting, play an expert specialist role in the care, treatment and support of people with dementia. The knowledge and skills outlined at this level become increasingly role and context specific.
The knowledge and skills outlined at each level follow on from each other. For example, staff who operate at the Dementia Enhanced Practice Level would also have the knowledge and skills, attitudes and behaviours described at the levels before.
Roles in health and social care differ, so the framework does not point out any specific health and social care staff roles in the domains. Each staff member and their employer must make sure they understand and work to the content of the framework as it relates to their role when working with people with dementia, their families and carers.
Stages of the dementia journey
Dementia follows a well-recognised pathway of progression. The framework uses the pathway as a structure, although we understand that the needs of people with dementia, their families and carers will be different at different stages, and that the dementia journey will be unique for each person.
Receiving a diagnosis of dementia is not the starting place for the framework. Helping to prevent the onset of dementia, and supporting people to keep good health and wellness, are also vital. A targeted public health approach to dementia risk reduction and prevention has a specific focus in national work on dementia from 2021 led by Brain Health Scotland, which is funded by the Scottish Government and hosted by Alzheimer Scotland.
The four stages of the dementia journey identified in the framework are:
- Keeping well, prevention, and finding out it's dementia
- Living well with dementia
- Living well with increasing help and support
- End of life and dying well
Quality of life outcome indicators for people with dementia, their families and carers
Work done by the Alzheimer's Society in 2010 showed that people can have a good quality of life following a diagnosis of dementia, and that the domains in general quality of life measures are as relevant to people with dementia as more dementia-specific domains. The views of people with dementia, their families and carers on the relevance of the quality of life outcome indicators developed for the original 2011 Promoting Excellence framework were sought through a recent consultation. With some small changes, these were still found to reflect the views of people living with dementia, their families and carers.
The quality of life outcome indicators are at the heart of the framework and encourage staff and services to think about the impact and end results of the support, care, interventions and treatments they provide against these indicators. The quality of life outcome indicators reflect the new Standards for Health and Social Care and their underpinning principles.
Health and Social Care Principles
- Dignity and respect
- Responsive care and support
- Be included
Health and Social Care Standards
- I experience high-quality care and support that is right for me.
- I am fully involved in all decisions about my care and support.
- I have confidence in the people who support and care for me.
- I have confidence in the organisation providing my care and support.
- I experience a high-quality environment if the organisation provides the premises.
Quality of Life Outcome Indicators
01 People with dementia have access to a timely and accurate diagnosis of dementia that includes high-quality support before, during and after their diagnosis
02 People with dementia feel empowered and enabled to exercise rights and choice, maintain their identity and be treated with dignity and equity.
03 People with dementia have access to individuals, groups and organisations that can support their spiritual or personal beliefs and reflect their cultural wishes.
04 People with dementia have access to quality services and can continue to participate in community life and valued activities.
05 People with dementia maintain their best level of physical, mental, social and emotional wellbeing.
06 People with dementia feel safe and secure and are able to be as independent as possible.
07 People with dementia are able to maintain valued relationships and networks and have the opportunity to develop new ones, both personal and professional.
08 People with dementia, with their families, friends and carers, have access to the information, education and support that promotes their rights and enhances their wellbeing.
"Once the word dementia comes into a conversation, people more or less dismiss you. They think you have no views, no thoughts of your own; you can't speak for yourself, you can't do things for yourself and you have a very, very difficult job persuading these people to listen to you, to take you seriously and to get help of any manner or kind, because they're very dismissive. All of a sudden, you become useless. This is not the case." A person living with dementia