Allied Health Professionals Dementia Framework

Allied Health Professionals

Dementia Framework

for Wales

Maximising the impact of Allied Health Professionals in Wales

working with people living with dementia 2022–2025

Mae’r ddogfen hon ar gael yn Gymraeg hefyd / This document is also available in Welsh

Rydym yn croesawu gohebiaeth a galwadau ôn yn Gymraeg / We welcome correspondence and telephone calls in Welsh

Illustration credit: ‘The Sea of Uncertainty’ – Frances Isaacs

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Contents 
 
Forewords ........................................................................................................................... 2 
Foreword by Andy Woodhead PhD, living with dementia and a member of the Framework 
Project Steering Group ....................................................................................................... 2 
Foreword by Ruth Crowder, Chief Allied Health Professions Advisor, Welsh Government 3 
Acknowledgements and with thanks to ............................................................................ 4 
Executive Summary ........................................................................................................... 5 
Glossary .............................................................................................................................. 6 
Introduction, context and vision ....................................................................................... 8 
Vision .................................................................................................................................. 8 
Audience ............................................................................................................................ 8 
Purpose .............................................................................................................................. 8 
National context: dementia in Wales .................................................................................. 9 
AHP Supporting Values .....................................................................................................13 
Wider strategy, policy and context .....................................................................................14 
A Human Rights-based approach ......................................................................................15 
 An evidence-informed approach .......................................................................................16 
AHPs: A whole system tiered approach to care and support ........................................18 
Universal support ...............................................................................................................20 
Targeted support ...............................................................................................................25 
Specialist support ..............................................................................................................30 
Future roadmap to AHP practice in dementia .................................................................48 
Quadruple priorities ...........................................................................................................48 
Priority 1: Awareness and Access to AHPs .......................................................................49 
Priority 2: Improvement and Innovation .............................................................................51 
Priority 3: Co-production and Collaboration .......................................................................52 
Priority 4: Leadership and Learning ...................................................................................55 
Future directions ................................................................................................................57 
References .........................................................................................................................58 
 
   

Forewords

Foreword by Andy Woodhead PhD, living with dementia and a member of the

Framework Project Steering Group

A diagnosis of dementia is not something that is easy to receive. There is no miracle cure,

so a fear sets in which you know everyone experiences but there is always bravery,

optimism and acceptance to be found. Dementia is a condition which ultimately affects the

whole family, as they join us in our journeys, which although different for everyone, will

require care and expertise. It is vital that we remember that dementia is not only a condition

which affects older people, and everyone with one of the over a hundred forms of this

condition is different. We do not however want to carry the ‘dementia’ label, to define who

we are on this journey with this illness; it is crucial to remember that ‘I’m Still Me’!

Staying positive, happy and accepting is hard but we have to do it for our family and friends.

Those who work in the caring roles are the happy faces, with the compassionate nature and

constant help, which means that a life can feel comfortable, safe, secure and bearable

again. We are able to believe that it is possible to live a better life than we thought possible

with dementia. The sacrifices carers make is not something that immediately springs to

mind as it should. The strain on families can be enormous and it is imperative that they

have the advice, support and care they need too when it is requested.

The Allied Health Professionals (AHP) Dementia Framework for Wales most importantly will

provide much needed hope and encouragement to those living with dementia, with holistic

and person-centred care at its ‘core’. The AHP approach to our care will ensure that we are

receiving the right support post-diagnosis.

The fact that this framework has been developed through co-production, seeking out the

opinions, experiences, desires, needs and challenges of those living with dementia, our

families and carers, has been indispensable in putting together a strategy that we can feel

confident should be fit for purpose.

It is exciting to see that we now have the opportunity to implement a framework across

Wales that is going to mean so much to improve the lives of so many people. Dementia

care has for a long time been fragmented and complicated in some respects for many to be

able to navigate and access. This will be changed for the better by the AHP Dementia

Framework. This is not something that will necessarily be easy. It is going to require

structural change, resources, learning, commitment, co-operation and a change of culture if

it is going to evolve well.

The opportunities for dementia care in Wales through the AHP Dementia Framework are

going to be a challenge, but I know that the desire is there amongst all the stakeholders to

make this initiative work. Everyone who has contributed to the development of this project

are owed a special debt of gratitude. I know how much work and effort has gone into this.

As a person living with dementia, with a family supporting me through my journey, I am so

proud to see that Wales / Cymru are leading the way and blazing a trail in Dementia Care

and ultimately, improving the quality of our lives.

Foreword by Ruth Crowder, Chief Allied Health Professions Advisor, Welsh

Government

This is an important, exciting and challenging time to be an Allied Health Professional

(AHP). The Allied Health Professions are 13 individual professions

allied by our belief in

the importance of enabling citizens to live the lives they want to live. Yet the unique

expertise of each profession has traditionally been poorly understood and under-utilised.

This Dementia Framework has identified strong themes that every AHP, manager and

employer needs to understand and act on if we are to ensure that our population achieve

the best possible health outcomes.

The engagement work underpinning this framework has received clear messages from our

colleagues and population. They tell us that we need better, easier and quicker access to

our services. In particular, they need to reach us far earlier in their health journey than they

do at present, to maximise brain health, to reduce risk of dementia, and to enable people to

live a life of quality following a diagnosis. They tell us that we need to communicate more

effectively the benefits our interventions and skills deliver, and that we need to work more

co-productively and collaboratively with people with dementia and their families. This will

enable us to better understand what people actually require and adapt our services to meet

their needs even more effectively in future.

This framework gives us a clear set of actions to deliver the changes required to modernise

and improve services across Wales. We need to innovate more and actively promote an

improvement culture within our services. We need increased capacity and skills for

research to enhance our evidence base and demonstrate impact, outcomes and value of

AHP approaches. We need to communicate far more clearly when and how we can offer

interventions that make a difference to the quality of people’s lives and to help them live

well with dementia. We must make access to our services less complicated and remove the

hurdles to people reaching the right professional at the right time. We must be located in,

and work as part of, local communities in partnership with our population.

People with dementia may have other conditions and need to access all parts of the health

and social care system, so these actions need to apply to every AHP, not just those in

specialist dementia services. Each and every one of us will need to embrace leadership

and use our skills to change the narrative about what good dementia care should look like

and champion a rights-based approach so that people with dementia can access the

services and support that they are entitled to.

AHPs across Wales must transform our approach so that we are delivering more

preventative interventions at times that will help people live a life of quality post-diagnosis.

AHPs in Wales: • Art Therapists • Music Therapists • Drama Therapists • Dietitians • Occupational

Therapists • Orthoptists • Orthotists • Paramedics • Physiotherapists • Podiatrists • Practitioner Psychologists •

Prosthetists • Speech and Language Therapists

Acknowledgements and with thanks to

Many people have worked in partnership to co-produce the Allied Health Professionals

Dementia Framework for Wales. We want to thank the AHP Dementia Framework Steering

Group, with membership including people living with dementia, carers and supporters,

health and social care professionals, third sector organisations, AHP professional bodies

and higher education institutions (HEIs) (Appendix 2

)

We would also like to extend gratitude to the partners who have supported this work:

• Age Cymru

• AHP Policy Officers

• Allied Health Professionals Dementia Network

• Alzheimer’s Society Cymru

• Alzheimer’s Society Dementia Voice

• Bangor University

• Cardiff University

• Carers and supporters

• Diverse Cymru

• Health and social care practitioners

• Health Education Improvement Wales

• Lleisiau Dementia

• Local NHS Health Boards

• People living with dementia

• Social Care Wales

• TEC Cymru

• Together in Dementia Everyday (tide)

• Welsh Ambulance Service

• Welsh Government

• Welsh Regional Partnership Boards

Thanks is extended to Frances Isaacs for her kind permission to use her paintings

throughout this publication.

Lead author: Laura Braithwaite Stuart

Suggested citation:

Welsh Government (2022) Allied Health Professionals Dementia Framework for Wales:

Maximising the impact of Allied Health Professionals in Wales working with people living

with dementia 2022-2025. Available at: https://gov.wales/allied-health-professionals-

dementia-framework-wales

Available on request. Please email: HSS.RehabAndAHPs@gov.wales

Executive Summary

• The Allied Health Professionals (AHP) Dementia Framework for Wales

defines the value of the enabling, holistic and person-centred approach to

care and support that is offered by all Allied Health Professionals.

• The framework is relevant to people living with dementia, their

carers/supporters, AHPs, together with AHP managers, health and social

care sectors, and the third and independent sectors.

• Developed through an evidence-informed approach, the framework has

been shaped by listening to people living with dementia, their carers and

supporters, using an appreciative inquiry approach to understand what

good care looks like, together with appraisal of research evidence and

exploring opportunities, challenges and ambitions for dementia care from

perspectives of AHP leaders. This work has been guided throughout by a

steering group with lived and learnt experience of dementia.

• A whole system, tiered approach to care and support is offered within the

framework, aligning with prudent healthcare principles, ensuring that people

with dementia receive the right care, in the right place, at the right time

(Welsh Government, 2019). Case studies are used throughout the

framework to evidence excellent practice taking place across Wales.

• Priorities to continue the transformation of AHP practice in dementia are

focused around increasing awareness of and access to AHPs,

strengthening innovation and improvement approaches to continue building

evidence of the value of AHP approaches, enhancing co-production and

collaboration to achieve what matters most to people with dementia and

developing leadership within the AHP workforce at all levels of the health

and social care system to drive change in AHP practice.

• These priorities align with wider policy and strategy including the Dementia

Action Plan for Wales (Welsh Government, 2018), All Wales Dementia

Care Pathway of Standards (Improvement Cymru, 2021) and AHP

Framework for Wales: Looking Forward Together (Welsh Government,

2019), Primary and Community Care Allied Health Professions (AHP)

Workforce Guidance: Organising principles to optimise utilisation (Strategic

Programme for Primary Care, Wales, 2021) and the All Wales

Rehabilitation framework and guiding principles (Welsh Government, 2022).

Glossary

Allied Health

Professionals

In Wales, Allied Health Professionals (AHPs) are 13

individual professions regulated by the Health and Care

Professions Council (HCPC). AHPs work with people of

all ages, from birth through to end of life, empowering

and enabling them to manage their own wellbeing and

prevent or reduce the impact of psychological and

physical ill health and disability. AHPs work across

health, social care, private practice and charity

organisations.

Biopsychosocial

approach

A theoretical framework to understanding health and

wellbeing. The biopsychosocial approach takes into

account the biological, psychological and social factors

that may influence a person’s overall participation in their

everyday life.

Carer /

supporter

A person who supports or cares for a person living with

dementia. Other terms such as caregiver, care partner,

relative, family member, friend, aid or helper may also be

used in place of carer/ supporter.

Co-production

The process of working with people who use services

and carers in a collaborative partnership to plan, improve

and deliver care, support and services. This leads to

meaningful change.

Peer support

This refers to opportunities for people with dementia and

their carers/supporters to meet other people who also

have dementia or care for a person with dementia. Peer

support can be valuable in enabling people to share

experiences, coping strategies and build new, supportive

relationships in a safe space.

People affected

by dementia

This may include a person living with dementia, a carer

(unpaid or paid), family members, friends or health and

social care professionals.

Person-centred

A person-centred care approach seeks to see the

individual person, rather than concentrating on their

dementia. Person-centred care recognises and respects

the personhood, diversity and human rights of the

person.

Rehabilitation

Rehabilitation describes support, care and interventions

that help people to achieve and maintain optimal levels of

functioning. This helps people to retain their

independence and life roles for as long as possible,

ultimately enhancing quality of life. Reablement is an

enabling approach focused around supporting people to

retain or regain skills within everyday life, and may form

the restorative component of rehabilitation.

Strengths-based

approach

A strengths-based approach recognises the strengths of

a person, their family, groups and communities around

the person and empowers them to achieve what matters

to them. The approach recognises the abilities, interests,

knowledge and resilience of the person, rather than their

limits, in comparison to traditional deficit-focused models.

Stress and

distress

Distress describes communication or behavioural

changes in people with dementia that may be present as

a response to stress, often resulting from an unmet need,

such as pain, discomfort, need for connection, lack of

meaningful activity or sensory needs. How a person

experiences stress and presents with distress will vary

person to person.

This may also be described in other documents or

existing research as ‘Behaviour that challenges’,

‘Challenging behaviour’ and ‘BPSD (Behavioural and

Psychological Symptoms of Dementia)’.

Supported self-

management

This explains how someone with expert knowledge,

including people living with dementia, health and social

care professionals, and third sector organisations can

support people with long-term conditions to develop the

knowledge, skills and confidence to manage their health

and wellbeing in order to continue to do what matters to

them.

Team Around

The Individual

The team supporting the person living with dementia.

This may consist of family, friends, supporters, members

of the community, in addition to a team of health, social

care, third sector/charity professionals, and dementia

navigators, who provide co-ordinated care, that is flexible

and tailored to the needs of an individual person with

dementia and their carer.

Introduction, context and vision

Vision

‘People living with dementia, their carers and families, will have enhanced access to

the enabling, empowering support, care and rehabilitation that Allied Health

Professionals can provide, regardless of their age or address, gender, sexuality, or

ethnicity, earlier in their diagnosis, and throughout the course of their dementia.’

The Allied Health Professionals (AHP) Dementia Framework for Wales outlines how Allied

Health Professionals (AHPs) in Wales can help people living with dementia, their carers

and supporters to remain as physically, cognitively and socially active for as long as

possible, to live a life of quality following their dementia diagnosis. The framework also

details the AHP contribution to brain health of the population, reducing risk of developing

dementia, in addition to supporting people to access a differential and timely diagnosis.

This framework works from the lens that ‘dementia is everybody’s business’, and for Wales

to become a dementia-friendly nation as outlined the Dementia Action Plan, we need all

AHPs, wherever they work, to be able to deliver person-centred, enabling and holistic care.

Audience

Though our key audience is members of the 13 AHPs across Wales, we recognise that the

work of AHPs is dependent on partnership working and integration across all sectors of

health and social care. Therefore, we believe that this document will be essential reading

for anyone involved in delivering and planning services for people living with dementia, and

specifically:

• People living with dementia, carers, family members and supporters

• AHP Leaders

• Health and social care managers

• Regional Partnership Boards

• Welsh Government

• Third sector and charity organisations

• Wider public

Whilst this framework was developed in Wales, it is realised that it may influence the work

of others across the United Kingdom. Consideration of progress made in our equivalent

nations has been acknowledged within this framework (Alzheimer Scotland, 2017).

Purpose

This framework provides an evidence-informed approach to demonstrate the value of AHPs

in promoting brain health, and supporting people living with dementia and their

carers/supporters.

The AHP Dementia Framework for Wales aims to:

• Outline the offer of AHPs in brain health, dementia risk reduction and increasing

public awareness of dementia

• Define the role and contribution of AHPs in empowering people to live a life of quality

after diagnosis

• Champion the voices of people with dementia and their carers/supporters, and what

they tell us matters to them

• Present the most current research evidence regarding the support, interventions and

rehabilitation provided by AHPs in enabling people with dementia, their carers and

families

• Showcase emerging best practice taking place within AHP communities across

Wales

• Serve as an evidence-based resource that can be called upon to affect change and

support influencing work in Wales, from service level to policy level

National context: dementia in Wales

Dementia is one of the fastest growing causes of disability across the world and is

recognised as a global public health priority (WHO, 2021).

It is estimated that there may be approximately 55,000 people living with dementia in Wales

(Jones, 2018). Of course, the impact of dementia is far-reaching, with potential effects on a

whole family. People living with dementia can experience a decline in their memory,

thinking, perception, language, movement and other areas of functioning that have the

potential to reduce participation in everyday activities. These difficulties worsen over time

and can impact on a person’s quality of life, and that of their family members who provide

care and support.

COVID-19 and dementia

People with dementia and their carers/supporters were disproportionately affected by the

COVID-19 pandemic. Research suggests that lack of social contact and change in routines,

in addition to loneliness and isolation as a result of the pandemic, have led to a significant

decline in cognitive and physical abilities, as well as increased mental health needs for

many people with dementia and their carers (Giebel et al, 2020; Greenberg et al., 2020,

Masterson-Algar, 2022). This means that there is an increased level of need in terms of

rehabilitation for people with dementia to regain and maintain skills to facilitate

independence and wellbeing. Increased waiting time for diagnosis following disruption to

services, delays in access to support and the need for more mental health support for

people with dementia and their carers/supporters (Alzheimer’s Society, 2020) mean that

AHPs will continue to have a vital role in facilitating rehabilitation and recovery.

“It is estimated that there are

approximately 55,000 people

living with dementia in Wales”

(Jones, 2018)

“The number of people living with

dementia in the UK is predicted to

rise to 1.1 million by 2030, 1.4 million

by 2040 and 1.6 million by 2050”

(Luengo-Fernandez and Landeiro, 2022)

“82% of people affected by

dementia reported an increase in

dementia symptoms as a result of

COVID-19 lockdown”

(Alzheimer’s Society, 2020)

Rehabilitation

The World Health Organisation global call to action highlighted dementia as a core

recommendation (World Health Organisation, WHO, 2017). Rehabilitation is equally as

important for people with cognitive impairment as well as physical impairments (Cations et

al., 2018). Dementia rehabilitation should be centred on the principle of enabling people to

function optimally in the context of their intrinsic capacity and current health status (Clare

2017). This needs to be person-centred, focused on strengths and what a person can do,

maintaining focus where possible on promoting quality of life from early symptoms to later

stages of a person’s dementia journey (Laver et al. 2020). Despite recognition that AHPs

are leaders in rehabilitation, there is currently a lack of access to AHP specialist dementia

rehabilitation in dementia care (Welsh Government, 2018).

There is also a clear role for AHPs in the prevention of dementia. Livingston et al (2020)

identified 12 modifiable risk factors for dementia, including obesity, diabetes, diet, reduced

social contact, depression, physical inactivity, hypertension and excessive alcohol

consumption, all of which can be influenced by AHPs’ interventions.

Allied Health Professionals (AHPs)

AHPs work creatively and with a strengths-based approach to provide support to people

across the lifespan, enabling people to do what matters to them. They use their expertise

and experience, combined with research evidence in collaboration with individuals and key

people in the person’s life to provide tailored care and effective support. Making up

approximately one third of the NHS workforce (Welsh Government, 2019), AHPs are

leaders in rehabilitation, focusing on solutions to empower people to lead a good quality of

life. Examples of job profiles of AHPs supporting people with dementia are available at the

bottom of this page

Within Wales, there are 13 AHPs working across health, social care, the charity sector and

private practice, and are registered with the Health and Care Professions Council (HCPC).

Who are AHPs, and how can they help people?

Art Therapists

Art therapists provide a form of psychotherapy that uses art media as its

primary mode of expression and communication to address clinical

goals. Used in a therapeutic context, art is a medium to identify and

address psychological, emotional and well-being issues which may be

confusing and distressing.

Music

Therapists

Music therapists use different elements of music to help people to

achieve therapeutic goals and work with their feelings using music. This

may be receptive (listening to the music) or active (making music).

Neurologic Music Therapy (NMT) specifically relates to music therapy

that can positively impact cognitive, sensory and motor symptoms of

neurological conditions.

HEIW Allied Health Professions Job Profiles

Dramatherapists

Dramatherapists are both clinicians and artists who use performance

and theatre-based methods, including drama, story-making and

movement, as a means to engage a person in psychological therapy.

Dramatherapy is a form of psychotherapy.

Dietitians

Dietitians assess, diagnose and treat diet and nutritional problems. They

also provide holistic interventions and practical advice to optimise a

person’s nutritional intake to improve their health and wellbeing.

Dietitians work on an individual and wider public health level.

Occupational

Therapists

Occupational therapists provide tailored assessment and interventions to

help people to maximise their functional abilities to carry out the

activities that are important to them that enhance quality of life. This

could include everyday activities, like getting dressed, cooking, shopping

as well as hobbies and pastimes.

Orthoptists

Orthoptists diagnose and manage any difficulties associated with eye

movements and co-ordination.

Orthotists

Orthotists design and provide specialist devices (orthoses) which

support the body with the aim to improve function, reduce pain, provide

protection and reduce deformity.

Paramedics

Paramedics work with people who are in a health or social care crisis.

They provide advanced emergency care.

Physiotherapists

Physiotherapists specialise in promoting and helping people to maintain

movement, through activity and exercise. Physiotherapists can also help

with management of pain that may impact on movement, independence

and quality of life.

Podiatrists

Podiatrists enable people to maintain healthy feet, helping people to

remain mobile, prevent falls and promote independence.

Practitioner

Psychologists

Practitioner psychologists use psychological theories to understand how

the brain works and to understand behaviour. They can assess,

diagnose, treat and support people who have experienced changes in

their mood and behaviour. Practitioner psychologists can help people to

develop coping strategies and adjust to difficult life events.

Prosthetists

Prosthetists assess for, design, create and fit artificial limbs for those

who those who have lost a limb through injury or disease, or were born

without a limb.

Speech and

Language

Therapists

Speech and Language Therapists provide tailored assessment, advice

and interventions to support people who have communication difficulties.

They also provide support for people with eating, drinking and

swallowing difficulties.

AHP Supporting Values

Although there are 13 distinct Allied Health Professions (AHPs), there are common values

and approaches that unite AHPs when working with people living with dementia and their

carers and supporters.

The Allied Health Professions Dementia Network for Wales explored the unique values that

AHPs can bring when supporting people living with dementia and agreed on three key

values. AHPs are committed to an enabling, person-centred and holistic approach to

delivering care, support and interventions. These three values reflect the universal AHP

strengths-based approach, which is underpinned by kindness and understanding.

Enabling: Allied Health Professionals adopt an enablement approach to supporting the

person with dementia, using their knowledge, skills and expertise to enable them to make

informed choices about the care and support they would like to access and inspire hope.

Using a strengths-based approach, AHPs use creative approaches to advocate for a

person, helping to make their voice heard, facilitating participation and promoting their

human rights.

Person-centred: Allied Health Professionals work in a way that is person-centred,

relationship-centred and family-centred, tailoring interventions to the individual, to take into

account the values, needs and identity of the person with dementia and those around them.

Holistic: Allied Health Professionals use the biopsychosocial approach to support the

person with dementia, recognising the impact of the environment around the person and

the need to work collaboratively across boundaries, agencies and sectors to achieve the

best outcomes for the person and their carers/supporters.

Underpinned by

Kindness & Understanding

Figure 1 - Allied Health Professional Values

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Wider strategy, policy and context 
The Allied Health Professionals (AHP) Dementia Framework for Wales aligns with key 
policy documents. 
The Dementia Action Plan for Wales 2018-2022 (Welsh Government, 2018) sets out the 
vision for creating a dementia-friendly nation where the rights of people with dementia and 
their carers are recognised and they feel valued and respected. The ‘Strengthening 
provision in response to COVID-19’ (Welsh Government, 2021) document complements the 
Dementia Action Plan, and identifies the need for ongoing work in targeted areas. Of 
particular relevance to Allied Health Professionals (AHPs), it highlights the need for further 
development and evaluation of ‘Teams around the individual’ that are multi-professional 
and can deliver integrated, person-centred care. Additionally, the need to improve access to 
therapeutic interventions and rehabilitation for people living with dementia, which in turn 
reduces the use of antipsychotic medications, is also reinforced in the strategy. 
The All Wales Dementia Care Pathway of Standards (Improvement Cymru, 2021) contains 
themes focused on supporting independence and self-management, concepts at the heart 
of AHP practice. Implementation of the AHP Dementia Framework for Wales will support 
the embedding of the Dementia Care Standards. 
Furthermore, the ‘Taking Memory Assessment Services (MAS) into the Future’ (Surr, 
Cartwright, Platt, Robinson and Smith, 2021) improvement guide promotes the need for 
good quality peri- and post-diagnostic support for people living with dementia, including 
access to information, education, rehabilitation and peer support. AHPs have a key role 
here in supporting people through the assessment process, and empowering people to live 
a life of quality after diagnosis. 
Guidelines detailed within the Wales Dementia-friendly hospital charter (Improvement 
Cymru, 2022) are important for AHPs working within hospital settings as key principles to 
improve the experience of people living with dementia and their carers in hospital.  
The Good Work Framework (Care Council for Wales, 2016) defines the learning and 
development needs of the health and social care workforce, including AHPs, who may 
support people living with dementia and their carers. The framework identifies three broad 
groups of people: those who are at ‘Informed’, ‘Skilled’ and ‘Influencer’ levels, depending on 
the requirements of their role. The framework emphasises the importance of practice that is 
compassionate, competent and wise, and a toolkit has been developed to support 
implementation of the approach to learning and development. 
The AHP Dementia Framework for Wales, its values and approach also align with the goals 
set out in A Healthier Wales (Welsh Government, 2018), which highlights the role of health 
and social care professionals in providing prudent healthcare that is preventative, out of 
hospital and closer to home, with a focus on wellbeing and supporting people to remain 
independent within their community. The quadruple aim sets out the future vision for a 
‘whole system approach’ to health and social care in Wales: 
-  Improved population health and wellbeing;  
-  Better quality and more accessible health and social care services;  
-  Higher value health and social care; and  

- A motivated and sustainable health and social care workforce.

The AHP Framework: Looking Forward Together (Welsh Government, 2019) outlines how

AHPs will rise to the challenge to put into practice the vision of A Healthier Wales. This

strategic response highlights the culture shift needed for citizens to access AHP services

that facilitate rehabilitation, reablement and recovery. The framework highlights the need for

AHPs to be utilised more efficiently in order to inspire the population to lead healthier lives,

being directly accessible, providing evidence-based interventions working at the top of their

ability, as transformational leaders.

The Primary and Community Care Allied Health Professions (AHP) Workforce Guidance:

Organising principles to optimise utilisation (Strategic Programme for Primary Care, Wales,

2021) provides the organising principles and actions required for the whole health and

social care system to maximise the impact of AHPs across primary and community care.

The guidance promotes the need to ensure that sustainable models of delivery exist and

that AHPs are deployed from a well-integrated, whole system workforce planning basis to

deliver the high quality, high value services required. Ensuring effective accessibility and

utilisation of AHP skillsets across primary and community care is paramount to the delivery

of person-centred support, within a place-based care model of care.

A Human Rights-based approach

Dementia Statements

The Dementia Statements clearly state what matters most to people living with dementia

and their carers. Founded in human rights law, the statements were created by people

living with dementia and their carers to help embed a rights-based approach to care and

support and are emphasised within the Dementia Action Plan for Wales (2018-2022):

• We have the right to be recognised as who we are, to make choices about our lives

including taking risks, and to contribute to society. Our diagnosis should not define

us, nor should we be ashamed of it.

• We have the right to continue with day to day and family life, without discrimination

or unfair cost, to be accepted and included in our communities and not live in

isolation or loneliness.

• We have the right to an early and accurate diagnosis, and to receive evidence-

based, appropriate, compassionate and properly funded care and treatment, from

trained people who understand us and how dementia affects us. This must meet

our needs, wherever we live.

• We have the right to be respected, and recognised as partners in care, provided

with education, support, services, and training which enables us to plan and make

decisions about the future.

• We have the right to know about and decide if we want to be involved in research

that looks at cause, cure and care for dementia and be supported to take part.

In addition to the dementia statements, it is vital to highlight that people living with dementia

have a right to access rehabilitation, including specialist AHP rehabilitation. Access to

rehabilitation is a human right (Low and Laver, 2020).

Welsh Language and Dementia

The Welsh language is an integral element in the care and support of many Welsh

speakers, but some groups have an even greater need to receive their services in Welsh.

This is especially true for people living with dementia when it can be more than a matter of

choice – it is a matter of need.

People with dementia are entitled to receive health and care support services in their

preferred language. Communicating in a language that is most comfortable for the person is

paramount in getting the right treatment and support, accurate and timely assessment and

respecting the person’s culture and personhood. The Welsh Language Measure (Welsh

Government, 2011) sets out the rights for people to receive services in Welsh. The active

offer is particularly important for people living with dementia who speak Welsh as their first

language and as dementia progresses, may only be able to use or understand Welsh. This

is supported by the More than just words Plan 2022-27 (Welsh Government, 2022), which

stresses that people should be able to access services in Welsh without needing to request

them, known as the ‘Active Offer’. Realising this vision is the responsibility of everyone in

their respective fields so that people receive care that meets their language needs, leading

to better outcomes, without having to ask for it.

Diverse communities

People from diverse groups may face more barriers in relation to accessing person-centred

care. Accessing timely diagnosis and appropriate services following diagnosis may be more

difficult for people from black, Asian and minority ethnic communities, lesbian, gay, bisexual

or transgender (LGBT) communities, those with young-onset dementia, people with sensory

impairment, people with learning disabilities, and people living in rural communities (Welsh

Government, 2018). AHPs must recognise and respond pro-actively to health inequalities

and appropriately meet the needs and rights of specific groups, who may also be at higher

risk of developing dementia, to ensure provision of holistic, person-centred care, avoiding a

‘one-size fits all’ approach.

“Dementia is life-altering,

not life-ending”

An evidence-informed approach

The framework has been developed using multiple methods to gather evidence and

demonstrate impact

More detail regarding the evidence-informed approach used to develop the framework can

be found in Appendix 1

Available on request. Please email: HSS.RehabAndAHP[email protected]

Project Steering Group

Listening Events

AHP Leader Survey

Research Review

Guided by a group of

people living with dementia,

carers, health and social

care professionals, charity

sector and AHP policy

officers provided guidance

and expertise

Connecting with people living

with dementia and their

carers/supporters to find out

what matters to them

Informed by professionals

working with people with

dementia and their families,

including Dietitians,

Occupational Therapists,

Podiatrists, Physiotherapists,

Practice Psychologists and

Speech and Language

Therapists

Scoping review of the current

research evidence to examine

post-diagnostic AHP

interventions

AHPs: A whole system tiered approach to care and support

What is the tiered approach?

A tiered approach to care means that people living with dementia and their

carers/supporters can access the right support, in the right place, at the right time. A multi-

level approach to AHP care, support and interventions helps to embed rehabilitation and

enablement culture to all areas of dementia care.

Why is it relevant to people living with dementia and their carers/supporters?

The tiered system can be used to apply a whole system approach to dementia care,

recognising the complexity of the condition. The approach reflects the need for the AHP

workforce to be integrated into all areas of health, social care and third sector services for

people with dementia, to ensure that work is holistic, collaborative, and cross-cutting across

organisational boundaries, ultimately enhancing the experience of people with dementia,

their carers and supporters.

How does the tiered approach work?

The framework provides a holistic approach by identifying all core elements needed to

deliver high quality outcomes for a population; in this case, people at risk of developing

dementia, or those who have a diagnosis of dementia, and their carers/ supporters. The

model includes details around ‘what good looks like’ at universal, targeted and specialist

levels, underpinned by a skilled workforce, strong leadership, meaningful co-production with

people living with dementia and their carers, and collaboration with the wider workforce.

People with dementia and their carers/supporters can access support at multiple levels at a

time, depending on their needs, and can move seamlessly between each level.

Universal: Promoting independence and wellbeing, building resilience and preventing

escalation of needs.

Targeted: Working collaboratively with others to improve the wellbeing of people living with

dementia.

Specialist: A range of individual AHP-led interventions, delivered by both generalist and

dementia-specialist clinicians to provide rehabilitation and enablement approaches.

It is important to highlight that whilst some AHPs will have specialist roles working only with

people living with dementia, in the context of an ageing population and increasing multi-

morbidity, a significant proportion of AHP workforce will work with people living with

dementia. Here, the level of ‘specialist’ is defined as interventions that are AHP-led and

accessed depending on the complexity of the person’s needs, rather than accessing a

clinician who works specifically in a dementia-specialist role. It may be that within the

specialist level, there are AHPs working in enhanced or expert roles, within dementia-

specialist services.

The approach provides the platform to begin conversations about how AHP services

respond to people living with dementia and their carers/supporters now and in the future.

AHPs: A whole system tiered approach to care and support

Figure 2 - Tiered approach to AHP dementia care

Specialist

Targeted

Universal

Universal support

The universal level of support is focused around prevention, self-management and

promoting independence, and is available to everyone. Here, AHPs are using their skills to

empower and support people living with dementia to access information, support, and

resources as early as possible that can enable them and their carers to live a life of quality.

All AHPs may deliver support at a universal level.

Support at this level may include:

- Promotion of the importance of brain health and reducing risk of dementia.

- Provision of population level advice and signposting to people with memory

difficulties or dementia, and their supporters.

- Awareness raising with the wider workforce, third sector and members of the public

regarding the AHP offer in supporting people living with dementia.

- Promotion of a rehabilitation and rights-based approach to supporting people with

dementia and their carers/supporters.

- Indirect support to all people with dementia and their carers/supporters using

multiple, inclusive communication methods including websites, social media, videos,

blogs and evidence-based resources.

The following sections explain key components of the universal level approach to care, with

examples of practice across Wales and beyond.

Supported self-management and education

AHPs will share at population level self-management tips to enhance physical, cognitive

and psychological wellbeing. Focus on using AHPs’ skills to facilitate self-management can

support people to maintain independence for longer before requiring more targeted,

therapeutic interventions. This can help people with dementia to remain at home, avoiding

unnecessary hospital admissions and potentially delay admission into a care home (Quinn

et al. 2015).

Education and provision of information can support resilience in people with dementia and

their carers.

The Movement and Mobility strategy paper, poster and resources, linked to Standard 9 of

the All Wales Dementia Care Pathway of Standards (Improvement Cymru, 2021), aim to

raise awareness, of the importance of physical activity following a diagnosis of dementia.

The resources promote the value of movement and mobility in enhancing physical,

cognitive, and emotional wellbeing, and can work as a reminder within primary care

settings, GP surgeries, outpatient and rehabilitation settings, Memory Assessment

Services, and community venues.

AHPs have also been central to the development of the ‘Conversations about dementia’

syllabus, a national education programme which provides a range of free self-management

courses to support people living with a health condition and/or their carers (Improvement

Cymru, 2022).

Resources about managing everyday ‘risks’ have been developed by Occupational

Therapists in ABUHB to help people living with dementia and their families to take a

positive approach to everyday activities and feel more confident. These include getting out

and about in the community, leaving the house and cooking. Carers and family members

can also learn new techniques to support their family member.

Likewise, the Footcare at home leaflet, developed in partnership by podiatrists in Scotland

and Alzheimer’s Scotland and modified for use in Wales, provides advice to people living

with dementia to promote good foot health before problems develop. The leaflet also

highlights when a person with dementia should seek further support from a Podiatrist.

Making every contact count is an approach that helps people to take control of their own

health and wellbeing. Health professionals can have supportive conversations with people

about their diet, physical activity, smoking cessation, alcohol intake and mental wellbeing.

AHPs are well-suited to conversations about making healthy lifestyle choices and can

empower people to make changes to their lifestyle through short interactions as part of

routine appointments. This approach to optimising brain health aligns with the ‘twelve steps’

to reduce the risk of dementia from the World Health Organisation (WHO, 2019), as

outlined in the Dementia Action Plan companion paper (Welsh Government, 2021), as well

as the commitment to ensuring that people with dementia receive advice about changes

they could be supported to make to improve their overall health and wellbeing. AHPs can

be involved in promoting brain health at public health level and have a fundamental role in

the prevention of many lifestyle-related conditions.

Awareness and influencing

The Dementia Action Plan highlights that stigma and discrimination can prevent people

with dementia from seeking help and support that can help them to live a life of quality

(Welsh Government, 2018). Scoping and engagement work suggests that the role of AHPs

is not yet fully understood by people with dementia and their families, as well as other

health social care professionals, such as GPs and nurses.

The role of the National Consultant AHP Lead for Dementia maximises the contribution

of AHPs in rehabilitation and enablement approaches in dementia care, in partnership with

others, at a national level.

The AHP Dementia Network for Wales, a forum that provides national clinical leadership

for AHPs across Wales, has begun to bring about transformational change in terms of

activities to raise the profile of AHP interventions and the impact of working with people with

dementia and their families. AHPs can champion the voices of people with dementia, their

carers and families, in whatever setting they work, and can work alongside involvement

groups, such as Lleisiau dementia, 3 Nations Dementia Working Group and Dementia

Engagement and Empowerment Project (DEEP), to ensure that experts by experience are

involved in shaping their care and support, and the services delivered in the future.

AHP membership within national forums such as the Welsh Government Dementia

Oversight Implementation and Impact Group (DOIIG), together with Dementia Regional

Boards, can also facilitate space to advocate for the need for strengths-based approaches

to dementia care.

AHPs can use creative and accessible methods to educate members of the public together

with professional colleagues about the importance of rehabilitation approaches and the role

of AHPs. Examples shared across Wales include videos and blogs about job roles, social

media to share evidence-based advice and awareness campaigns during key events, such

as AHP day and World Alzheimer’s Month.

With Podiatry You Can postcards are one example of the ways that AHPs can raise

awareness of the support available to people with dementia. Developed in partnership by

Royal College of Podiatry in Scotland and Alzheimer’s Scotland, and modified for use in

Wales, and adapted and adopted for use in Wales, the postcards explain the role of

podiatrists and key areas in which they can support people with dementia to enhance

mobility and retain independence.

Promotion of dementia-supportive environments

AHPs have a key role in promoting dementia-supportive environments by advocating the

need for a rights-based, rehabilitation approach in dementia care. AHPs’ values promote

personhood, participation and positive risk-taking, supporting a biopsychosocial model of

care that encourages inclusivity, citizenship and a strengths-based approach (Alzheimer

Scotland, 2017).

People living with dementia want to continue to access their local communities and to

continue to engage in or join new community organisations that are beneficial for their

wellbeing. Therefore it is important that these environments understand the needs and

aspirations of people with dementia. Using their skills and creativity, AHPs can be called

upon to support the development of dementia-friendly communities that recognise and

value the contribution of people living with dementia, and to challenge stigma associated

with dementia, ageing and disability, so that people can maintain social roles and feel

connected to their communities.

The development of the Dementia-friendly hospital charter outlines the key principles of

dementia-friendly hospital care. The charter promotes care that is enabling and encourages

the person’s strengths, skills and abilities in the support and interventions provided. It also

encourages the use of positive, empowering language in place of prescribed disablement.

AHPs can also advise on the creation of enabling physical environments for people with

dementia. AHPs can help to ensure that people with dementia receive healthcare in spaces

that meet their sensory needs, enable people to communicate effectively and to live as

independently as possible.

Digital inclusion

People living with dementia want to be able to access evidence-based information that

helps them to build resilience, develop coping skills to remain as independent as possible

and to stay connected with their community. Digital participation is a key part of this and

can have significant benefits in terms of health and wellbeing of people living with dementia

and their carers.

All AHPs have a role in supporting people with dementia to access technology, where

appropriate, that can help them to keep well. Digital technology can be used to assist with

everyday life, aiding orientation, facilitating online shopping, serving as a memory prompt

for appointments and medications, and to aid cognitive stimulation. Technologies can also

facilitate social connection and interaction, through reminiscence, video-conferencing and

access to social media, which can provide a platform for peer support and engaging with

the community (Talbot and Briggs, 2022).

Despite misconceptions about technology, older people and dementia, we know that people

with early-stage dementia may use technology to learn new skills and develop confidence,

providing a sense of achievement, which in turn challenges the narrative and stigma around

Case study - ‘Get There Together’

‘Get There Together’ was a national project developed to support people living with

dementia in adjusting to their surroundings due to Coronavirus (COVID-19) restrictions.

Many people living with dementia and their carers expressed that they felt fearful and

worried about going back into their local community when COVID-19 restrictions eased.

This included going to community shops, support groups, together with going to

healthcare appointments. People reported that they had lost skills and confidence due to

isolating or shielding at home for a prolonged period.

The project, led by Dr Natalie Elliott, National Consultant AHP Lead for Dementia, was

developed in partnership with health and social care professionals, including AHPs,

people living with dementia, businesses and partners across Wales, and was supported

by Digital Communities Wales. Digital stories, consisting of pictures, videos, voiceovers

and text, provided advice regarding COVID-19 safety measures, and showed how key

environments may look different. The films aimed to reduce anxiety and isolation as

people started to go out again into their local community.

All resources are accessible, available in English and Welsh, and in printed formats

alongside digital versions. The digital stories can be found on the Dewis Cymru website.

It was felt that the resources were important in helping people to re-integrate into their

community and daily life.

dementia. Technology can provide a platform for people to engage in research, providing a

sense of purpose and citizenship within society. There is an increasing community of

people living with and affected by dementia forming online communities, which can help

people to cope with their diagnosis, and reduces feelings of social isolation (Shu and Woo,

2021), particularly significant in areas where access to face-to-face post-diagnostic support

may be variable. People with dementia should have equal access to technology, including

those living in rural areas where additional challenges to receiving support may exist. It is

recognised that digital exclusion and the digital divide, resulting from a range of complex

factors, can create additional barriers for people living with dementia, their carers and

supporters in accessing timely and effective care and support.

Community Partnerships

AHPs are ideally placed to work with people with dementia as part of a whole system,

integrated approach to care.

Local meeting centres or Dementia hubs for people with dementia and their carers

situated within the community can be a rich source information and practical support. Hubs

can help to connect people with dementia to their community and services around them,

signposting people to the right support at the right time, including when to seek help from

AHPs. AHPs may also provide long-arm input to dementia hubs, providing information and

resources about social, cognitive, and physical health interventions that can help people to

live with dementia.

Links with third sector and community groups are key to encouraging people to keep

active physically and socially, and enhance wellbeing. Social prescribing with a focus on

what matters to the person can also lead to a variety of positive health and wellbeing

outcomes, preventing further needs at a later stage. Community-based arts and health

interventions, such as visual art groups, dementia choirs, dance groups and theatre groups,

can provide opportunities for people to learn new skills, maintain a sense of purpose and

remain socially connected within their community. AHPs will signpost people with dementia

to local services that enrich people’s lives through activity.

Peer support

It is vital that AHPs connect people with dementia, their carers and supporters to peer

support networks. People with dementia tell us that peer support, meeting other people with

dementia, who understand how dementia affects their life, is key to living a life of quality

after diagnosis. Social interaction in a safe environment, opportunity to share practical

coping strategies and emotional support are important to developing a support network,

maintaining independence and mental wellbeing (Keyes et al. 2016).

Targeted support

Targeted support describes the role of AHPs in supporting others to care for the person

with dementia. AHPs at this level may provide supervision, training, coaching or

consultation with others in order to enhance the quality of life of the person with dementia.

AHPs understand the inherent relationship between a person with dementia and their

environment. Sharing skills and knowledge with key networks around the person with

dementia is vital to supporting effective and co-ordinated joint working, improving outcomes

for the person and their carers. Learning may take place in a range of settings and formats,

from formal person-centred courses and accredited certifications, to more informal

shadowing opportunities, critical discussions and team reflections to continually improve the

experience of dementia.

Learning, training and development

AHPs work closely and collaboratively with other health and social care professionals,

together with colleagues in voluntary and community services, housing and private

organisations, to deliver the best outcomes for people with dementia. Working together in

partnership with others to share skills and knowledge can support with embedding AHP

approaches to rehabilitation and enablement. AHPs recognise that in order to deliver

effective, person-centred care, there is an important role in developing the skills of others to

meet the needs of people living with dementia.

AHPs may be embedded within Health Board Learning and Development teams to deliver

training and learning opportunities that align with the Informed, Skilled and Influencer levels

outlined in the Good Work Framework (Care Council for Wales, 2016). With examples

across Wales of occupational therapists, physiotherapists, practitioner psychologists, and

speech and language therapists as part of multi-disciplinary teams, AHPs can facilitate

engaging and enriched learning environments that support others to make a difference in

their work with people with dementia, wherever they work. Learning focused around

relationship-centred care, positive communication approaches, meaningful activities,

supporting carers and families, managing stress and distress, maximising physical health,

and increasing independence through positive risk-taking are just some of the areas to

which AHPs can apply their values in sharing skills and knowledge in supporting good

dementia care.

The AHP workforce also delivers evidence-based training and guidance regarding specific

symptoms of dementia, helping to prevent escalation of needs, unnecessary

pharmacological approaches and avoidable hospital admissions. Supporting the

development of knowledge and skills focused on key concepts within AHP practice, such as

moving and handling, nutrition and hydration, dysphagia, falls prevention, sensory

accessibility, and mental capacity and decision-making can enable others to deliver

enhanced care and support.

Using robust tools to aid quality assurance, monitoring and evaluation of the training are

key to ensuring that learning is embedded within practice, and ultimately, to understanding

the impact on the person with dementia. Magic Moments is an example of an approach that

can be used by AHPs to reflect on real life experiences and support continuous

improvements in dementia care (Improvement Cymru, 2021).

Case study - Magic Moments from Dementia Care Training in Cwm Taf Morgannwg

University Health Board

The training is developed and delivered by an Occupational Therapist and Mental Health

nurse. The training consists of three levels of training, covering the ‘Informed’ and ‘Skilled’

levels of the Good Work Framework. The Level 3 training (Skilled) is recommended for

anyone involved in ‘hands-on’ adult care, from any profession and any level of qualifications.

Face-to-face sessions provide opportunities to develop knowledge and skills based largely

on the work of Teepa Snow (an American Occupational Therapist). A variety of teaching

methods are utilised, including PowerPoint presentations, film clips, and group discussions,

with an emphasis on being as experiential as possible. Monthly virtual Support and

Development sessions are also offered, with the aim of building on what people have learnt

in the Level 3 five-day training package.

Magic moments - staff putting learning into practice

Community Mental Health Physiotherapist “I have used the Hand under Hand® technique

to support a patient to drink. Previously, she would only take a tiny sip of juice, but now she

will drink half a glass during our session. Family have also started using the technique and

she is drinking with them.”

A Nursing Assistant in a General Ward laid down under the hospital bed with a gentleman

who needed to “mend the car”. The gentleman was safely and meaningfully engaged for 1 ½

hours because she stopped seeing everything as ‘dangerous’ or ‘risky’ and used a person-

centred approach to understand what the person needed.

Staff Nurse Mental Health Ward “There is one gentleman with whom 50% of our

interactions had a negative outcome. From this course, I realised it wasn’t the patient or their

dementia; it was me and my approach. Since the training, our interactions have been 100%

positive. The person has been in a positive place. This has made me feel I made a small

difference to their day, which has made a positive difference to me also.”

Case study - ‘Train the trainer’ approach to implementing person-centred, meaningful

activities in care homes: A pilot project

Background to the project

The Alzheimer’s Society reports that 70% of people in care homes have dementia or

undiagnosed cognitive difficulties. It is often reported that many people living in care homes,

often those living in later stages of dementia, have difficulty participating in meaningful

activities. The pilot project was formulated as part of a set of action plans laid out by

Wrexham Council Borough Council (WCBC) Contracts and Commissioning team, which was

in response to a review of the Quality of Life and Care of People Living in Care Homes in

Wales, A Place to Call Home? (Older People’s Commissioner for Wales, 2014).

The Progression Service action was to pilot a project with 2-3 care homes focusing on the

development of meaningful and bespoke activities on what matters to individuals and to look

at a positive risk-taking culture in order to enable residents to maintain their independence

and autonomy. It was envisaged that by working directly with the activity coordinator in each

care home, they could then cascade learning to other staff within the care home.

Project Aims:

- To support the use of person-centred activity plans by introducing and giving relevant

training to the activity coordinators on the use of the Pool Activity Level (PAL) Instrument

Occupational Profiling (Pool, 2012).

- To advise and train on other strategies to support engagement in meaningful activities to

include communication techniques, sensory stimulation, equipment and environmental

factors.

- To develop in-house training and resources for care staff based on the “Living Well with

Activity in Care Homes” toolkit, College of Occupational Therapy COT (2013), so that the

activity coordinators had the resources to cascade learning to other staff within the care

home.

Collaboration with Health and Social Care

During the planning stage of the pilot, meetings were held with the Lead Occupational

Therapist at the local Older Person’s Mental Health Unit, as it had been established that the

PAL was used routinely with people admitted to the older people’s wards. The PAL

paperwork had been redesigned by the Occupational Therapy staff at the unit, to make it

more user-friendly. It was agreed to use their PAL paperwork, with a potential of creating a

unified “engagement passport”; a document that can be transferred across health and social

care settings, e.g. between hospital, community and care home, to provide an immediate

understanding of the person, their background and occupational needs.

The Care Homes and Residents Involved

In total three care homes were involved, with three residents from each care home. The care

homes were chosen due to activity coordinators who came forward with an interest to be

involved. Residents identified to be involved with the project were chosen after discussion

with Activity Coordinators, Occupational Therapy, the Person-Centred Planner (PCP)

coordinator, as well as the care home manager. They considered who may benefit most,

particularly those who had previously experienced difficulties engaging in activities. Most of

the residents on the pilot project had some degree of memory difficulties.

Coaching and supervision

Supporting a workforce that is engaged is key to ensuring a whole system approach to

enabling people with dementia. A key component of creating effective learning

environments is to prioritise staff wellbeing (Kings Fund, 2015). When staff are treated with

compassion and respect, with space to deliver creative and innovative care through

collective leadership, and able to feel psychologically safe when things go wrong, people

with dementia also receive care that is more compassionate and effective.

AHPs can empower colleagues to reflect on their own skills and expertise in supporting

people with dementia, drawing together resources and experiences to continually improve

practice. Co-producing solutions to clinical challenges can enable health and social care

The Occupational Therapist Role

After gaining consent, the Occupational Therapist made regular visits to the care home (at

least once a fortnight) to introduce the PAL concept, with the proposed outcome of creating a

personalised activity plan based on the person’s confirmed level of engagement. During

visits, the Occupational Therapist observed and worked with residents and the activity

coordinators during the activities they engaged in, essential for assessing the residents’

ability levels and noting their interaction with their environment. This meant that the

appropriate guidance and training could be given to the activity coordinator to complete the

PAL. This also provided time to evaluate opportunities and barriers to engagement in

meaningful activities and assess similarities and differences between the three care homes,

as well as helping to identify the potential areas needed for staff training.

Project impact and outcomes

• Overall, the pilot project demonstrated that the PAL could be used as a valuable tool to

identify appropriate person-centred activities that had meaning for residents as well as

being used as an outcome measure.

• There was a common theme that more support is required from all care home staff to

ensure a more enabling approach is used for meaningful activity provision. Supporting

engagement in meaningful activity is everybody’s (all care home staff) business not just

the activity coordinators’ and this is an approach that needs to be embedded as part of

residents’ daily routines. To address this, in-house training is planned to be implemented

by the Occupational Therapy and PCP coordinator, initially in the care homes involved in

the pilot project. This training will also provide information on other important aspects,

such as communication techniques and environmental changes, which also contribute to

support meaningful activity provision.

• The pilot project provided a unique opportunity to work with the health sector and it is

hoped that this collaboration can be developed further to support people, especially those

with dementia, to maintain their skill levels during hospital admissions.

• Involvement in the pilot project also highlighted positive initiatives that are being

implemented around the local area to support people with dementia. It could be that these

initiatives are linked more effectively to create a more unified approach.

• Ultimately, there is work that can be done which will benefit the well-being of vulnerable

people living in care homes so that they feel that they do live in a place that they can call

home.

professionals to take ownership of their workplace and recognise the contribution that they

make to enhancing the quality of life of the person with dementia.

Case Study - Ask Us About Dementia, a pilot study

Technology Enabled Care (TEC) Cymru (2022)

‘Ask Us About Dementia’ pilot is a national support service for dementia, virtually connecting

families and the paid workforce to advice from dementia practitioners. The pilot service was set up

as a collaboration between Social Care Wales, the National Consultant AHP Lead for Dementia,

and Tec Cymru. The service was available to both family carers and health and social care staff to

book online video consultations with dementia practitioners from various specialities, such as

dietetics, nursing and speech and language therapy. The pilot service began as a response to the

pandemic and operated from September 2020 until the end of April 2022.

The aims of the service were:

• To provide timely access to advice and signposting on dementia care using telehealth

• To increase awareness of the Allied Health Professions and improve access to their

expertise

• Support peer learning between health and social care practitioners

• Prevent escalation of needs and crisis where possible

The service was developed through co-production, engaging with key stakeholders including

practitioners, pilot sites and people with lived experience of dementia.

Clinicians utilised a coaching model to support callers to collaboratively work through possible

solutions and take ownership to commit solutions to action. Themes from calls taken included diet

and nutrition, communication, mobility and exercise, advice around COVID-19, and general

information about dementia.

Two independent evaluations of the pilot service were undertaken, one for the period September

2020 – April 2021, and the second for the timeframe between May 2021 and April 2022. The

evaluation was undertaken by TEC Cymru, including a survey and telephone interviews.

Family and paid carers involved in the evaluation of the service had an extremely positive

experience accessing it. Carers had explained that the service had enabled them to access

support that would not have otherwise been easily available, and generally found the technology

easy to use in terms of booking appointments and accessing the session with the practitioners.

Feedback from practitioners taking part in the project was very positive, with 100% of dementia

practitioners from the survey reporting that they felt the pilot service achieved its aim of providing

timely access to expert advice and signposting on dementia care through the use of video

consulting, as well as supporting peer learning between health and social care

practitioners. 100% of practitioners also reported that they had positive experiences of using

‘Attend Anywhere’ as the delivery platform for the pilot service sessions. Over 80% of practitioners

felt that the pilot service had increased awareness of AHPs and enhanced access to their skills

and expertise through video consultations.

Following the success of the pilot project, options for further roll out of the service will now be

explored.

Consultation

The AHP workforce may be called upon to provide expert advice and consultation into local

and national networks, influencing practice and policy across health, social care, third

sector, and academic forums, alongside people with dementia and their carers.

Opportunities for collective learning in collaboration with others, co-creating knowledge with

a wide range of stakeholders can influence change in practice at a whole system level and

enhance the experience of people with dementia receiving care and support (Care Council

for Wales, 2016).

Reflection on case studies and stories, understanding research evidence and considering

‘what matters’ to individuals means that AHPs can work as part of wider, interdisciplinary,

multi-organisational teams to change ways of working and build evidence of approaches.

‘The Sea of Uncertainty’ depicting the experience of receiving a

diagnosis of dementia, by Frances Isaacs

Specialist support

The specialist level of care and support refers to AHP-led interventions that are tailored to

an individual to provide person-centred rehabilitation. This care, support and rehabilitation

may be delivered by generalist or dementia-specialist clinicians in enhanced services,

depending on what the person and their family needs.

Within this section, examples of support provided by each of the AHPs in relation to

dementia are explored. Case studies are used to illustrate the impact of these interventions,

together with research evidence from the literature review (Appendix 3 - available on

request. Please email: [email protected]).

Across the various professional groups, the research evidence together with the

experiences of people with dementia, suggests that early intervention, focused on what

matters to the person, delivered in people’s homes and familiar environments, in

collaboration with carers and family members, is most effective (Abraha, Rimland & Trotta

et al., 2017; Pentland, 2015).

Arts Therapies

Arts Therapies is a collective term that describes music therapy, art therapy, dramatherapy

and dance movement psychotherapy. In subsequent sections, the evidence base and

Case Report – Expanding Arts Therapies provision

(Elliott and Older Adults Arts Therapies Service (OAATS) team, 2021)

A six-month pilot project took place in an NHS Health Board in South Wales to expand

access to arts therapies, in response to need for increased direct therapy for people with

severe cognitive impairment and significant communication difficulties, secondary to

dementia and/or complex mental health difficulties. Effectiveness of the service was

measured using observer feedback forms together with feedback from colleagues. Demand

for the service was also measured by recording the number of referrals received.

The team consisted of two art psychotherapists and four music therapists, providing support

to people in both community and older people’s mental health inpatient settings. The people

living with dementia taking part were unable to complete feedback forms, and so family

members observing sessions, in addition to staff members, completed evaluation forms

based on their observations. Analysis of observer feedback forms taken from a snapshot of

six weeks of clinical interventions showed positive improvements in communication, mood,

confidence, ability to express emotions and engagement.

All therapists involved in the project reported that members of staff across mental health

teams acknowledged the importance of the role of arts therapies in meeting the needs of

people with dementia. The project demonstrates the value of arts therapies in enhancing

wellbeing and supporting people to cope with the challenges associated with dementia and

complex mental health difficulties. The team have now secured partial permanent funding

for arts therapies in Older Adults services, pending further approval from Welsh

Government.

outcomes relating to art therapy, music therapy and dramatherapy are outlined as

recognised, registered AHP disciplines within Wales.

Art Therapy

Art therapy, or art psychotherapy, utilises visual art alongside verbal communication, to

support people to work with and make sense of their own thoughts and feelings and those

of others. Art psychotherapy is a form of psychological therapy and can be particularly

helpful for people with dementia who may have difficulty communicating, as art therapy can

provide an alternative medium for self-expression when words are not enough. Therapy

may be delivered to individuals or in group settings, depending on individual need and

preferences. There is promising evidence to suggest that art therapy can be beneficial for

people living with dementia in promoting cognitive and emotional health (Fancourt & Finn,

2019), and reducing feelings of apathy and depression (Fancourt & Finn, 2019; Parkinson,

Case study – Therapeutic Art as part of Specialist AHP Dementia Pathway

An eight week Therapeutic Art Group formed part of a specialist pathway, developed by

the Allied Health Professions (AHP) Dementia Team at Betsi Cadwaladr University

Health Board, working in partnership with Wrexham Borough Council.

The group was facilitated by one qualified and one trainee Art Therapist/ community art

practitioner. Sessions took place at the art studio within the Ty Pawb Community & Arts

Hub, Wrexham, as an accessible, de-stigmatising local venue. Referrals to the group

were co-ordinated by the group facilitators in partnership with the Occupational Therapy

team at Heddfan Older People’s Mental Health Unit, Wrexham Maelor Hospital.

The group aims were to ameliorate the social, functional, cognitive and psychological

functioning of participants. Skilled facilitation and a carefully devised range of creative

techniques were found to be significant to the overall positive outcomes. Activities

focussed on engaging participants in positive experiences and the introduction of

relevant themes through games, poetry, music, objects or images to stimulate

imagination, positive memories and conversation. A range of qualitative, quantitative

and anecdotal data was gathered to provide comprehensive outcomes information,

which included reduced feelings of isolation, improved social skills, enhanced cognitive

functioning, safe expression of thoughts and feelings, improved emotional regulation,

confidence and motivation.

“It all seems to be coming back to me, I used to do art.” (Participant)

“She was always extremely happy coming out of each class. She didn’t remember them

from week to week but when we helped her to remember she did have some memory.

I’m convinced that it helped her mood and for me as a carer that’s a big plus.” (Carer).

The project demonstrated the need for sustained and long-term therapeutic engagement

for people living with dementia and their carers. Community based therapeutic art

groups could be well utilised as part of a pathway for people living with the early stages

of dementia and would help maintain active engagement in the community.

Windle & Taylor, 2017). Some studies have found that art therapy can enhance

communication, reduce symptoms of anxiety, and increase meaningful activity and

connection with others (Hsai et al. 2020, Tucknott-Cohen and Ehresman, 2016). Provision

of arts-based interventions are also support the need for offering ‘psychosocial and

environmental interventions to reduce distress in people with dementia’ (NICE 2018).

Music Therapy

Music therapy is a psychological therapy that uses music as the primary means of

communication for a person and facilitates processing of emotions. Music therapy may

involve the person with dementia listening and responding to or making music and sounds,

singing or engaging in song-writing to achieve a therapeutic goal. Engaging with music in a

therapeutic setting in this way can support people with dementia to manage and process

emotions such as frustration and anger which may otherwise manifest as stress and

distress (D’Aniello et al., 2021).

Case study – Music therapy and dementia

The case study below demonstrates the impact of music therapy in empowering people

living with dementia. Names and personally identifiable information have been

anonymised to protect confidentiality.

Susan was 52 years old when I worked with her, and had a diagnosis of early onset

dementia.

She was still in employment but having problems in several areas of her life including

managing her duties at work, spiralling debt, housing and relationships. The initial goals

for music therapy were improved anxiety management, improved mood, and improved

self-esteem.

Susan was very uncomfortable talking about her feelings in general and was struggling to

even think about her dementia diagnosis: problems were piling up unaddressed in all

areas of her life.

Susan was able to use music making, and music and mindfulness techniques, as a bridge

to talking about her feelings and relationship patterns, exploring how avoidance had

protected her in past situations, but how she needed to find another way to face her fears

about her diagnosis and approach challenges using support. She used the space to

negotiate the transition from the working world and explore what living with dementia

meant for her personally.

Susan gradually became open about how much she was struggling, and a team, including

a social worker, was put in place. After building a supportive relationship in therapy, she

was then more confident to build relationships with other professionals enabling her to

articulate what was now important and meaningful to her, make the decision to resign from

her job, sort out her housing and debt problems, settle on medication, and commit to

attending appointments.

Robust evidence supports the use of music therapy in dementia. Benefits of music therapy

include improved communication, emotional wellbeing and self-esteem. Music therapy has

also been found to reduce depressive symptoms, anxiety, and stress and distress and

agitation, reducing the need for anti-psychotic medication (van der Steen et al (2018).

Recent research has also confirmed the effect of music therapy on reducing symptoms of

pain in people living with dementia (Achterberg, 2020) and may also have benefits in terms

of improving cognition, although further research is needed to confirm this (Bian et al.,

2021).

Dramatherapy

Performance arts form the basis of dramatherapy, to support people to work through

emotional difficulties such as depression, anxiety, bereavement and feelings connected to

their dementia. Therapeutic tools such as storytelling, puppetry, improvisation, movement

and embodiment are used by drama therapists, which enable the person to cope with and

manage their individual life experiences that may have been challenging or upsetting.

Similar to the other arts therapies, dramatherapy may provide an alternative form of

communication, empowering people with dementia to express their thoughts and feelings in

a way that may not be possible in their everyday life. It can be suitable for people at all

stages of dementia. More research is needed to examine the effectiveness of dramatherapy

using outcome measures. However, preliminary evidence suggests that dramatherapy can

improve meaningful social interaction, reduce symptoms of depression and enhance quality

of life overall (Lin et al., 2022).

Dietetics

Dietitians will undertake comprehensive nutritional assessments, to enable person-centred

recommendations to optimise nutrition and hydration. Eating and drinking well is vital for

people living with dementia, not only to maintain their physical health including maximising

their cognition, but also for their general wellbeing and to help retain their independence.

Eating and drinking is often the last activity of daily life that people living with dementia lose

and this can have a significant impact on the person living with dementia as well as those

who are caring for them (Prince, Guerchet, Albanese, & Prina, 2014).

People living with dementia are at increased risk of malnutrition and dehydration due to

many of the symptoms linked to dementia, for example: taste and sensory changes,

difficulty in recognising food, difficulty in cooking, forgetting to eat and drink, changes in co-

ordination and swallowing difficulties. However, they can also experience weight loss or a

reduced appetite due to other health co-morbidities or other factors linked with ageing. All of

these factors can lead to someone being at an increased risk of unplanned weight loss,

delirium, repeated infections, deterioration in dementia, falls and prolonged admissions to

hospital (Martin, Barrera Ortega, Dominguez Rodriguez, Couceiro Muino, de Mateo, and

del Rio (2012).

Dietitians can also provide support to help people maintain a healthy weight through a

balanced diet. Changes in mood, preferences for sweeter foods, barriers to physical activity

and the ability to plan healthy meals mean that a person could experience excessive weight

gain. Dietitians can advise on healthy alternatives to avoid health-related problems

associated with weight gain.

Changes in eating and drinking have been identified as a significant concern for carers and

families of people living with dementia (Abdelhamid, Bunn, Copley, Cowap, Dickinson,

Gray, and Hooper (2016). Dietitians play a fundamental role in supporting families to

manage the nutritional changes experienced with dementia (Jansen et al. 2015), but they

also support other healthcare professionals to optimise nutritional care across all settings.

This could be via training, information leaflets or via individual interventions and support.

‘Herewith Hedgerow Flowers’ depicting the hope of a new season

by Frances Isaacs

Case study – Dietetics and dementia

Background

Mrs P was referred to the dietetics service for support by the Admiral Nurse who was

supporting her daughter, who was her main carer. Mrs P’s daughter had become

increasingly concerned about Mrs P’s poor appetite. It was reported that Mrs P had lost

8kgs between December 2021 and February 2022 which the geriatrician had linked to her

advancing dementia.

However, in the weeks leading up to the referral to dietetics Mrs P’s daughter reported that

her mum was now eating very little. She had previously managed 3 small meals per day but

was now having no intake on some days and on other days was managing only mouthfuls of

preferred sweet foods. This significant reduction in intake coincided with Mrs P experiencing

loose bowel motions, leading to incontinence and so it appeared that she was restricting her

intake to prevent incontinence. Mrs P was subsequently diagnosed with a bowel infection

which was treated with antibiotics. The antibiotics caused oral thrush which was being

treated with nystatin but initially this further impacted Mrs P’s intake as her mouth was very

sore.

Mrs P had previously been able to come downstairs regularly to watch television with her

daughter as well as being able to mobilise independently to the bathroom situated down the

corridor. Since her bowel infection and reduction in intake, she was now mainly bedbound,

using a commode and spending more time sleeping during the day. Her daughter was

feeling very anxious and worried about the deterioration in her mum’s health.

Advice

• Provide and encourage small amounts of any preferred softer foods e.g. custards,

rice puddings, yoghurts, mousses. This would prevent discomfort from oral thrush but

may also encourage Mrs P to increase her intake slightly if they were foods she

enjoyed rather than trying to ensure a balanced dietary intake.

• All foods/ meals should be fortified (additional calories and protein added) where

possible.

• Offer home-made nourishing drinks to help with fluid intake as well as increasing

nutritional intake, e.g. hot chocolate

• Oral nutritional supplement changed from a milk based one to a juice based one to

try and improve compliance and prevent further weight loss while intake from diet is

so poor.

Impact

2 months post initial referral Mrs P had regained 2kgs, was eating 3 small meals per day as

well as snacks and fortified hot chocolates between her meals. Mrs P and her daughter

reported an improvement in her mood, she was now reading the newspaper and doing

puzzles again independently. She was also now able to mobilise independently to the

bathroom and went downstairs on most days to spend time with her family. She was also

eagerly making plans for her upcoming birthday celebrations.

Mrs P’s poor intake was not actually linked to her advancing dementia. It was instead

related to her physical health concerns, which once resolved with the help of nutrition

support, had allowed her to return to her baseline level of functioning and wellbeing.

Occupational Therapy

Occupational therapy focuses on enabling people to take part in activities that are

meaningful and important to the person (their occupations). Occupational therapists are

dual-trained in both physical and mental health care, and can support people to adapt to a

range of needs that may impact on everyday life. Continuing to participate in meaningful

occupations of daily life such as getting washed, dressed, preparing food, maintaining

hobbies and interests, and going to work are important for our mental health and wellbeing

(based on what’s important and meaningful to each individual). Retaining our roles within

our home and community life are fundamental to upholding our identity. As many people

developing dementia notice changes in their ability to carry out everyday tasks,

Occupational Therapists have the unique skillset to be able to assess cognition as part of

daily living ‘function’, and can therefore contribute towards assessment with differential

diagnosis of dementia, also helping the team around the individual to understand the impact

of memory changes on the person’s participation.

Occupational Therapists can support people by breaking down occupations into simpler

steps and/or find different ways of doing them to make it easier. They can advise on

improvements or equipment for the home to make things easier and support the person to

consider other adaptations such as technology, signage and memory prompts to make

things easier, supporting people to practice tasks in a way that increases skills and

confidence.

Personalised, tailored rehabilitation delivered by occupational therapists can support people

with dementia to continue to take part in their daily life, preserving self-worth, maintaining

skills and enhancing quality of life for the person with dementia and their carer. Originally

developed in Ireland, Home-Based Memory Rehabilitation (HBMR) is a structured,

evidence-informed programme (McGrath, 2013) that is currently offered by Occupational

Therapists in some Health Boards across Wales. HBMR helps people who experience

memory difficulties to develop strategies to cope with and compensate for memory

problems in everyday tasks. The programme uses repetition and structure to enable people

to integrate memory habits at an early stage that will be more likely to be remembered and

effective as the person’s memory loss continues.

Occupational therapists can also provide support in creating enabling environments (these

can be in homes, work settings, leisure settings or care settings). For example, specialist

assessment of the home setting can be beneficial in understanding how the environment

meets the person’s needs and supports wellbeing, independence and physical and mental

health. Personalised equipment or adaptations may be recommended as part of a positive

risk-taking approach, ranging from ramps, rails, and perching stools, to assistive technology

to facilitate memory prompts, social engagement or enhance safety (Bennett et al., 2019).

Joint working with physiotherapists, together with environmental modifications and telecare

can also enable people living with dementia to keep safe at home and reduce the risk of

falls. Recommendations regarding maximising vision, managing home hazards, and

attending to sensory needs of the person with dementia can be advised by occupational

therapists. Early adaptation of the home environment can be beneficial for embedding

techniques and maximising function for as long as possible.

Orthoptists

Orthoptists provide eye care for people with difficulties with the movement or co-ordination

of the eyes. This can include double vision, misalignment of the eyes, blurred vision, or

problems with the eyes that cannot be corrected by glasses. Difficulties with eye movement

Case study – Co-producing Occupational Therapy support in Memory

Assessment Service, Cwm Taf Morgannwg University Health Board

Following funding from Welsh Government, in line with the Dementia Action Plan and All

Wales Dementia Care Pathway of Standards, the first Occupational Therapy service in

Wales dedicated to Memory Assessment Service (MAS) has been developed through

true co-production with people living with dementia. From concept, through to design

and delivery of interventions, the Occupational Therapy service aims to 1) improve early

diagnosis and timely interventions for people experiencing cognitive changes, 2) better

inform the diagnostic process and identify occupational performance issues earlier in a

person’s journey, and 3) increase independence of individuals, remaining at home and

accessing local community.

The team provides an assessment of individuals’ occupational performance to inform

diagnosis (pre-diagnostic) and deliver early Occupational Therapy intervention (pre- and

post-diagnostic). They work co-productively with people living with dementia to

developing intervention programmes that embed focused strategies into individual

routines, including (but not exclusively) exploring the use of digital technologies.

Evaluation of service provision conducted using the Australian Occupational Therapy

Outcome Measure (AusTOMs) has evidenced significant positive changes in everyday

occupational performance for people living with dementia. Evaluation (at 3, 6, 12

months) indicates that despite the progressive nature of dementia, maintenance of skills

in line with the person’s own therapy goals has been achieved and sustained.

Feedback from people living with dementia and other Memory Assessment Team

members:

“I was struggling … but after having Occupational Therapy I feel like I have turned a

corner… thank you very much for all that you have done. I was misplacing items around

the home & had no independence using the cooker… I felt the strategies improved my

overall quality of life, & I saw the Occupational Therapist at the right time for me,

Occupational Therapy went above and beyond what was expected” (Person living with

dementia)

“Having occupational therapy as part of MAS has added value to our service and

establishing what skills and difficulties are happening by seeing the patient at home

gives an additional clinical perspective.” (Clinician)

Following the success of the service, the CTMUHB MAS Occupational Therapy team is

now evaluating their input and plan to share knowledge/evidence in working

partnerships across Wales and beyond, creating an Occupational Therapy MAS

provision blueprint and master classes to ensure a lasting impact.

can be caused by problems with the nerves that communicate between the brain and the

eyes, or due to changes to the muscles around the eyes.

An orthoptist may carry out assessment of visual acuity (clarity of vision) with a person with

dementia when they suspect changes in their vision. They can adapt the assessment tools,

using their skills to support the person to participate in the assessment as much as

possible. This helps to gain a clear picture of any visual difficulties so that the right support

can be offered to help the person, enabling them to adapt to changes in their vision and

maintain their independence.

Orthotics

Orthotists design and provide specialist devices (orthoses) which support the body.

Orthoses can have different objectives, like improving functionality such as walking,

reducing pain, providing protection, for example wearing specialist diabetic footwear and

insoles, or reducing deformity, such as preventing progression of musculo-skeletal

disorders. Orthotists therefore work in a range of healthcare settings, including treatment of

acute injuries, managing chronic diseases, or specialist clinics such as paediatric, musculo-

skeletal, or stroke and neurological disorders.

Orthotic services are often incorporated into diabetic services, where there is a higher

prevalence of dementia (Tasci, Safer, Naharci, Gezer, Demir, Bozoglu and Doruk,

2018). Other specialist clinics Orthotists are involved in are also likely to have a higher

prevalence of people with learning difficulties or brain damage who may show different

signs of dementia which can be more difficult to spot. As Orthotists review these individuals

regularly, they are well-placed to spot early signs of dementia, signpost to other services

that can support people experiencing changes in their memory and refer for cognitive

assessment.

Orthotists use a person-centred approach to increase the likelihood that when a person with

dementia requires their support, they provide an orthosis that successfully meets their

unique needs and requirements. Understanding the person, their routines, support systems,

and preferences, together with supportive communication, adapted assessment of pain,

and joint appointments with carers, can help a person with dementia to adapt to using new

devices.

Prosthetics

Prosthetists assess for, design, create and fit artificial limbs for those with congenital loss of

a limb as well as loss due to diabetes, reduced vascularity, infection and trauma.

Prosthetists empower people to regain their independence, move freely and enhance

participation in everyday life.

Research suggests that people with lower limb amputation are more susceptible to

developing dementia (Coffey, O’Keeffe, Gallagher, Desmond, and Lombard-Vance, 2012).

Many people who access Prosthetic services have co-existing long-term conditions such as

diabetes or vascular disease, which increase the risk of dementia (Tasci, Safer, Naharci,

Gezer, Demir, Bozoglu and Doruk, 2018). As prosthetists frequently support a key cohort of

patients, returning for review appointments on a regular basis over decades, they are well-

placed to identify changes in cognition, seek onward referral for cognitive assessment and

signpost to other services that can support people experiencing changes in their memory.

Prosthetists use a person-centred approach to increase success of rehabilitation when a

person with dementia requires their support. Knowing the person, their routines, support

networks, interests and preferences, together with supportive communication, adapted

assessment of pain, and repeated practice of exercises can help a person with dementia to

adapt to using limbs. Collaborative sessions with carers/ supporters can also be helpful in

embedding new exercises, techniques or strategies into everyday life.

Paramedicine

Paramedics play a crucial role in providing emergency care for people living in the

community.

Paramedics are frequently called out to support people with dementia in an emergency due

to the complex nature of dementia, and often due to co-existing health conditions that may

require treatment. Therefore, regardless of their role, most ambulance clinicians will

encounter people with dementia and their families, as well as people who may show

changes in their cognition, but do not yet have a diagnosis. People with dementia are more

likely to be admitted to hospital as an emergency than those without dementia (Buswell,

Lumbard, Prothero, Lee, Martin, Fleming and Goodman, 2014). Consequently, the role of

paramedics in providing person-centred, holistic assessment, that takes in account both

physical and mental health, is vital.

Case study – Person-centred care in Prosthetics

Mr H was an established prosthetic user, who had been known in the service for

decades. He started having problems with his prosthesis, with his GP referring for

prosthetic issues. At his first appointment, no issues were identified as Mr H knew the

service and his care well, and was orientated to his surroundings. However, when the

GP referred again shortly after with more severe skin issues, clinicians within the service

realised it may not be a simple prosthetic solution as the person was an expert user who

should have been able to problem-solve himself and avoid these issues occurring.

Clinicians working with Mr H started asking questions outside of his routine care, which

identified some concerns about his memory. Permission was gained from Mr H to

perform a cognitive screen which showed significant issues in memory, orientation and

cognition. The prosthetic service contacted Mr H’s GP and were able to use this

information to get him access to the help he needed, within 48 hours. He now has

access to the support he needs and has had no further prosthetic issues, keeping him

healthy and allowing him to lead a better quality life.

Physiotherapy

Physiotherapists are specialists in promoting and enhancing mobility. They work with the

person with dementia and their carers to encourage physical activity, to enable the person

to maintain their independence and participate in their everyday life for as long as possible.

Exercise programmes tailored to an individual’s needs can improve balance, co-ordination,

strength or cardiovascular health. Physiotherapy may also take place in group classes,

providing opportunities to socialise and have fun in a supportive environment, whilst

increasing physical activity through seated exercises, balance-led exercises or stretching

and strengthening exercises (Burton et al. 2015).

Physiotherapists have a crucial role in preventing and reducing falls in people with

dementia. People with dementia are at increased risk of falls (Hall et al., 2017), which can

have a significant impact on quality of life, reducing mobility, with potential for admission to

Case study - Becoming Dementia Friendly: Welsh Ambulance Services

The Welsh Ambulance Services are working towards improving the experience for

people living with dementia who use services, as well as considering the impact

dementia will have on the workforce. The vision of the Welsh Ambulance Service is to be

an organisation that responds to both the clinical and emotional needs of people living

with dementia, their carers and families. The service aims to be more dementia aware,

with a skilled workforce who deliver high quality services with improved experiences and

outcomes.

It is essential that Welsh Ambulance Services support people affected by dementia by

delivering person-centred care, at what can often be a frightening and distressing time,

particularly in an emergency. Staff believe that developing meaningful relationships with

people living with dementia is key, as well as using information that may be available to

them through carers, families and resources such as Alzheimer’s Society’s ‘This is me’

document. The more we know about the person with dementia the more we can tailor

our approaches, whether it involves using different communication techniques, changing

pace, or providing reminiscence therapy for meaningful activity or distraction.

“If I am transporting a patient, I like to know what they like to talk about and what’s

important to them. It is this kind of information that makes supporting a patient easier.”

Emergency Medical Technician.

Within the Welsh Ambulance Services Mental Health and Dementia Plan, there is a

commitment to create more optimal environments people with dementia, sensory loss

and other cognitive impairments. The service receives feedback where their

environments that include vehicles, processes, and staff interactions have an impact on

the experiences of people receiving support and care. People have told the service that

lighting, noises, lack of communication and reassurance, especially in an emergency,

can cause much anxiety. Welsh Ambulance Services are exploring improvements to

their environments, the skills and knowledge of the workforce and opportunities for digital

technologies to support effective, person-centred care approaches.

and prolonged stay in hospital. In collaboration with the person, their carer and family,

physiotherapists advise on personalised strength and balance programmes, postural

management and make recommendations to reduce the risk of potential fractures resulting

from falls.

Difficulties with communicating mean that people with dementia may also find it challenging

to express when they are in pain. Physiotherapists are skilled in assessing and treating

pain, and can provide personalised advice to enhance posture and seating to reduce pain

and increase comfort, which is particularly important in later stages of dementia (Peisah et

al. 2015). This can reduce symptoms of stress and distress as a non-pharmacological

approach.

Case study - Access to physiotherapy

Below is a case study example that evidences the value of physiotherapy in supporting

people living with dementia and co-existing mental health difficulties. Names and

personally identifiable information have been anonymised to protect confidentiality.

Mrs P, 65

Mrs P was admitted to the mental health ward as she was severely depressed and

confused. She had additional diagnoses of osteoporosis and chronic obstructive

pulmonary disease (COPD), and was dependent on oxygen for 18 hours daily. Mrs P was

treated on the ward with medication and on discharge was referred to the Community

Mental Health Team (CMHT) and allocated to the Clinical Specialist Physiotherapist for

assessment and care coordination. Holistic assessment identified that Mrs P’s depression

was secondary to her dementia and additional physical health difficulties. She had severe

anxiety and panic attacks, resulting in a fear of dying and not being able to breathe. She

also experienced lower back pain because of her osteoporosis, which was exacerbated by

her poor posture. Mrs P was constantly in forward flexed position trying to ‘get her breath’.

She was underweight with a body mass index (BMI) of 14 but no physical health

monitoring. There was no support in place for her carer at home, and Mrs P rarely left the

house due to her anxiety.

Physiotherapy intervention focused on: a) anxiety management using cognitive-

behavioural therapy (CBT) principles progressing onto graded exposure work; b)

supporting Mrs P to differentiate between anxiety and breathlessness due to COPD; c)

pain management and back care education; d) referral to dietitian and GP for physical

health management; e) referral to community matron for ongoing COPD management at

home; f) referral for carer support and carer assessment; and g) integration into

community groups (once she had developed coping strategies to manage her anxiety),

which gave her peer support from other people with dementia and social interaction.

CBT intervention and wider support resulted in Mrs P being able to reduce and eventually

come off benzodiazepine for her anxiety. Mrs P was able to enhance her quality of life and

wellbeing, due to increased ability to self-manage her healthcare needs as a result of

holistic, person-centred support from the multidisciplinary team, including physiotherapy.

Podiatry

Podiatrists are experts in foot health and can provide personalised advice to ensure that

people with dementia can keep active and maintain healthy feet.

A high proportion of people with dementia experience problems with their feet, which can

lead to increased risk of falls, reduced mobility and reduced confidence to take part in

everyday activities (López-López, Grela-Fariña, Losa-Iglesias, Calvo-Lobo, Rodríguez-

Sanz, Palomo-López, and Becerro-de-Bengoa-Vallejo, 2018).

Podiatrists provide tailored recommendations regarding foot care routines to improve

comfort and alleviate symptoms of pain. This can include specialist advice in relation to

supportive, well-fitting footwear, maintaining skin and toenails, and preventing ulcerations,

infections and soreness. Comprehensive assessment provided by a podiatrist can also

monitor for signs of other conditions such as circulatory problems or diabetes that can

impact on the physical health of a person living with dementia.

Practitioner Psychology

Practitioner psychologists are central to ensuring that the human rights of a person with

dementia are upheld and respected (British Psychological Society, 2016). Psychological

therapies can enable people with dementia to understand and the emotional impact of the

diagnosis and to consider how to maintain some control of their life and future, following a

diagnosis of dementia.

Practitioner psychologists can contribute to pre-assessment counselling, which helps

people accessing memory assessment to prepare for the possible outcome of assessment.

This is important in supporting people to adjust from an early stage, taking a strengths-

based approach, to explore their expectations and fears in relation to possibly receiving a

diagnosis. Practitioner psychologists use neuropsychological assessment to contribute to

the assessment and diagnosis of dementia. This builds a cognitive profile of the person,

highlighting strengths and weaknesses in order to support differential diagnosis. This can

help the MDT to distinguish between different dementia sub-types or a possible dementia

from cognitive difficulties caused by other conditions, such as depression or anxiety.

Practitioner psychologists offer a range of person-centred and family-centred approaches to

support people with dementia to live a life of quality after diagnosis. Talking therapies such

as Cognitive Behavioural Therapy (CBT), Narrative Therapy, Acceptance and Commitment

Therapy (ACT), and Compassion Focused Therapy include some of the approaches that

may be offered to help people with early-stage dementia to cope with the psychological

impact of diagnosis. This may often consider issues including roles, identity, relationships

and loss. Recent evidence from a large-scale systematic review suggests that CBT-based

psychological treatments are likely to reduce depression, enhance quality of life and

improve the ability to participate in everyday activities for people living with dementia

(Orgeta et al., 2022). Psychological therapies may also be offered in groups, where

participants can benefit from sharing experiences and connecting together (Cheston and

Howells, 2016).

Carers and family members may also benefit from talking therapies to support them in their

caring role. Family therapy, another form of talking therapy, can also provide a safe

environment for a person with dementia and family members to talk together about their

feelings with each other and how to support each other when things are difficult.

Practitioner Psychologists are also able to work with families and staff groups to support the

use of nonpharmacological approaches to stress and distress. Using psychological models

to assess the distress that someone may present with and the environment in which it

occurs, Practitioner Psychologists apply psychological theory to support teams and families

in making sense of the possible unmet needs for the person, as well as potential triggers for

stress.

Practitioner Psychologists have a role in supporting teams to work in psychologically

informed ways. This might include supporting the development of psychosocial

interventions in services, such as Life Story work, Cognitive Stimulation Therapy or support

groups. Practitioner Psychologists frequently offer supervision, consultation and training in

teams, in order to support the delivery of psychologically informed dementia care.

Psychosocial interventions and formulation-led approaches are recommended as first line

treatment for symptoms of stress and distress, and there have been a number of promising

studies to suggest that functional analysis-based interventions may be most effective in

reducing and distress in people living with dementia (Dyer et al., 2018).

‘Soon the poppies will appear’, by Frances Isaacs

Case study - Access to Psychological Therapy

Abigail initially accepted the suggestion of a referral for psychological therapy soon

after Stephen’s diagnosis with a young onset dementia. She identified that she

sometimes found it hard to know how best to support Stephen. She noticed that there

were times when she felt quite anxious. Her experience of her father’s dementia

connected with worries for her about the future. Gwenllian (Trainee Clinical

Psychologist) suggested the START programme for care givers of people living with

dementia, which Abigail was interested in. Strategies for Relatives of People Living

with Dementia (START) is a manualised Cognitive Behavioural Therapy (CBT)

intervention to help relatives develop coping resources. Abigail found this approach

helpful in identifying the ways in which her thoughts and feelings shaped her

responses to dementia. In particular, the opportunity to consider how to move from

worrying about the future to living more in the present was helpful to Abigail in

managing her stress and anxiety. Gwenllian and Abigail worked together to develop

skills in Mindfulness, which Abigail continues to use several years later. At this point

Abigail and Gwenllian felt that the outcomes they had discussed had been met:

Abigail felt better equipped to care for herself and Stephen, and had an improvement

in her experience of stress and anxiety.

Abigail requested follow-up from Psychology a year or so later to help her manage

feelings of loss and grief. Abigail had noticed that she had never been able to grieve

for her father, who had died around the time that Stephen developed his difficulties.

She also recognised the grief and loss she felt for Stephen, their marriage and her

imagined future. She feared this was impacting on her ability to care for Stephen.

Using Narrative Therapy, Emily (Clinical Psychologist) has attempted to help Abigail

connect with her values and her preferences for her life. For Abigail it has provided a

way of being able to reflect on her relationship with Stephen and to strengthen ways of

being together that are consistent with their values as a couple. It has provided a way

to reflect on identity and aspects of caring that may sometimes collide with this and to

think through what matters most. Abigail has been able to reflect on what has been

lost but also what has been learned in her journey. When there have been significant

challenges or changes that have affected the balance that Abigail and Stephen have

found we have met every 2-3 weeks. Mostly this has not been needed and Abigail has

simply valued a check in every couple of months. This is how she describes her

experience of therapy:

‘These conversations are so helpful and help me to clarify. They cleanse the mind. Life

is so full on, so much time preparing /doing, no time to step back and look. I can carry

on in a calmer, more knowing way. It helps to have this safe, quiet, isolated space to

think through; I can become a bit more objective. If I tried to do this on my own, I would

go round in circles but because you ask relevant questions it gives me a chance to

question my own thoughts and motives. It would be hard to carry on living with my

husband without this support. My husband gets lots of support, but this is all I get.

When I talk to you, I am thinking of my own life, which I feel I have been dragged away

from. I find this creative and a relief to talk about these things, knowing it is totally

confidential. I can find a way forward for me.’

Speech and Language Therapy

Speech and Language Therapy (SLT) can support people living with dementia who have

difficulty with their communication. This can involve difficulties with understanding

conversations, using words and sentences, or changes in reading or spelling. Difficulties

with taking part in conversations can have a significant impact on self-esteem, social

participation and maintaining important relationships. Most people with dementia will

experience some change in their ability to communicate and Speech and Language

Therapists work with people with dementia throughout the stages of their condition.

Difficulties with expressing needs and preferences can manifest as frustration, stress and

distress, leading to reduced wellbeing.

Speech and Language Therapists may work directly with the person to explore strategies to

help with talking and interacting. This may also involve exploring different forms of

communication (Alternative and Augmentative Communication/AAC), including verbal and

non-verbal methods, and supporting the person to plan for further communication changes

in the future. Facilitating communication can also extend to assisting people living with

dementia to make decisions about the care, treatment and support they receive as part of a

Mental Capacity Assessment (Jayes et al., 2020). It is important that carers and supporters

also know how to support the person with dementia in conversation. Carers and family

members propose that difficulties communicating can be one of the most challenging

aspects to deal with as a result of dementia (Egan et al., 2010). Frequently delivered by

Speech and Language Therapists, communication skills training has been shown to be

effective in increasing carer knowledge, skills, and resilience (Morris et al., 2018).

People with certain types of dementia, such as Primary Progressive Aphasia, may notice

changes in their speech as one of the earliest symptoms. Speech and Language Therapists

have a key role in assessment of cognition, communication, and speech, and are

fundamental as part of differential diagnosis of dementia within the multidisciplinary memory

team, enabling people to access tailored, early support for their communication needs

(Enderby, 2015).

Another significant role of Speech and Language Therapy is the assessment and

management of eating and drinking difficulties, and dysphagia (swallowing problems). Many

people living with dementia, particularly those with more advanced dementia, experience

difficulties with swallowing, leading to risks of malnutrition, chest infections, aspiration (food

and drink entering the airway), choking and reduced wellbeing. Speech and Language

Therapists provide advice on maximising safety of swallowing, using compensatory

strategies, such as texture modification, pacing, postural techniques, and adapting the

mealtime environment, whilst also balancing personal preferences, comfort and social

mealtime experience. Speech and Language Therapists are core members of the multi-

professional approach to managing complex eating and drinking issues, such as those

arising towards the end of a person’s life and decisions regarding ‘eating and drinking with

acknowledged risk (EDAR)’, when a person continues to eat and drink despite significant

risk of aspiration. Following holistic assessment, Speech and Language Therapists can

advise on the safest and least restrictive options for eating and drinking to maximise quality

of life and support decision-making that takes account of the risks and benefits for each

individual.

Case study - Speech and Language Therapy and Memory Assessment Services

Below is a case study relating to the role of Speech and Language Therapy in supporting

differential diagnosis and accessing early, evidence-based support following dementia

diagnosis.

Mr B had been referred to the memory service for assessment of his cognition, following

changes in his communication, attention, and executive functioning. He had previously had

a stroke. Speech and Language Therapy supported differential diagnosis as part of the

wider multidisciplinary team, due to consideration of a possible frontotemporal dementia,

as Mr B presented with significant language difficulties and relatively spared memory.

Holistic assessment confirmed that Mr B had vascular dementia. Despite his difficulties

with following conversation and word-finding problems, Mr B was satisfied with his

communication and did not require any direct therapy. However, Mrs B was struggling to

come to terms with changes in her husband’s communication, as he no longer initiated

conversations, struggled to find the right words and she felt he was no longer listening to

her.

Following assessment and diagnosis, the Speech and Language Therapist arranged a

series of four sessions with Mrs B to offer advice, skills training and support around

communication, also known as conversation partner training. Prior to therapy, Mrs B rated

her confidence as a communication partner at 5/10, explaining that she didn’t know how

best to support Mr B when he was unable to express himself. The sessions included:

• Psychoeducation regarding typical communication changes in vascular dementia.

• Detailed explanation of Mr B’s communication profile, detailing the strengths and

areas of need in terms of his speech, language, communication and cognitive skills.

• Discussion regarding potential communication strategies to trial, based on

assessment.

• Opportunity to trial strategies to enhance communication, with communication

activities for Mr and Mrs B each week between sessions.

• A review session to draw up final list of chosen communication partner techniques

and discussion around planning for communication changes in the future.

Following therapy, Mrs B expressed that she felt her knowledge about communication, and

dementia more generally, had grown significantly. She expressed that the sessions had

helped her to be more empathetic of her husband’s needs, enabling her to take his

perspective of the reality of experiencing communication difficulties as a result of his

dementia. Mrs B had also shared and discussed the techniques with her adult children,

and that they too had implemented the conversation partner techniques, such as writing

down key words and using photos to introduce conversation topics. Mrs B rated her

communication confidence at 9/10 at the end of therapy, and expressed that her anxiety

had improved significantly, as she felt reassured that she was ‘doing the right thing’.

This case study demonstrates the value of early Speech and Language Therapy input as

an integral part of multi-disciplinary memory assessment. Early, specialist support, focused

on the needs of the person and their family, can help to build carer resilience, supporting

mental wellbeing of carers and family members, ultimately also improving quality of life for

the person living with dementia.

Future roadmap to AHP practice in dementia

Quadruple priorities

With the introduction of national strategies and increased focus on dementia in Wales in

recent times, significant progress has been made in terms of the development of AHPs’

rehabilitation and enablement approaches that empower people living with dementia to live

a life of quality after diagnosis. We know that there is still considerable work to do if all

people living with dementia are able to access AHP approaches, regardless of their

address or age. People with dementia, their carers and supporters, together with

professionals and key stakeholders across Wales, highlighted four themes as key areas of

focus needed to continue the transformation of AHP care in dementia.

The four key priorities are:

Priority 1: Awareness and Access to AHPs

Increasing awareness of the role and contribution of AHPs amongst the wider health and

social care workforce, as well as members of the public, in optimising brain health and

maximising the wellbeing of people living with dementia and their carers/ supporters

Why is this important?

During our consultation, people living with dementia and their carers told us that they really

valued care and support that they had received from AHPs. People living with dementia

explained that clinicians had provided tailored interventions, flexible to their needs, and

involved their carers and family members which they viewed as important.

Whilst people living with dementia shared positive experiences of the support they received,

they told us that they frequently met barriers in attempting to access support from AHPs.

They highlighted a lack of information about what services are available post-diagnosis to

support rehabilitation, and felt that they did not know what to ask for. Many people outlined

frustrations with a lack of a structured pathway for support after diagnosis, following a

medicalised and deficit-focused approach to assessment. People living with dementia and

their carers were clear that they wanted to receive a multi-professional, holistic cognitive

assessment, including AHPs as appropriate, in line with evidence and similar to approaches

in other long-term conditions (Grand et al, 2011), which would enhance access to person-

centred, strengths-based interventions thereafter. Furthermore, people reported that they

often waited a long time to see an AHP.

People with dementia also highlighted a lack of information about future planning when

newly diagnosed. Many people expressed that they would like the ability to make informed

choices about their future care and support options to support self-management, agency

and resilience. This included knowing when and how to request support from AHPs months

and years ahead.

A recurring theme in our listening events with people living with dementia was that AHPs

were often only involved at crisis point, in terms of their physical or psychological health

needs. A number of carers also highlighted difficulties in accessing support when a family

member moved into a care home. People living with dementia, their carers and supporters

tell us that they would like involvement of AHPs at an earlier point, when they feel that they

can make a bigger difference. Research evidence suggests that early psychosocial

approaches offered by AHPs can help to delay the decline in cognitive and functional skills,

support maintenance of key relationships and quality of life (Laver et al, 2020). Engagement

in the development of the framework highlighted significant variation in access to AHPs in

early stages of dementia, in terms of both generalist and dementia-specialist provision.

The AHP Leader survey (Appendix 4

) revealed that many AHP managers and leaders in

Wales feel that other professionals, in addition to members of the public, are not aware of

the role of AHPs and what they can offer in dementia care and optimising brain health. In

order to increase early access to AHPs, we need to raise the profile of the impact of AHP-

Available on request. Please email: HSS.RehabAndAHPs@gov.wales

led interventions from the perspective of the person living with dementia, their carers and

supporters. Ensuring adequate recruitment of staff, in addition to sufficient AHP training

places to meet future demand, will assist with enhancing timely access to AHPs.

Call to Action:

1. Continue to promote the value of AHP-led interventions in supporting people living with

dementia, including population approaches to optimise brain health. Awareness-raising

across health, social care, housing and third sector settings and within local

communities, including meeting place or hubs, will align to Standards 1, 5, 6 and 11 of

the All Wales Dementia Care Pathway of Standards (Improvement Cymru, 2021).

2. Develop a national communications strategy for the Allied Health Professionals (AHP)

Dementia Network.

3. Increase access to multi-professional memory assessment, including AHPs, as

recommended in the Dementia Action Plan (Welsh Government, 2018), to ensure that

people receive timely, accurate diagnosis and tailored, evidence-based post-diagnostic

rehabilitation as early as possible. This action supports Standards 6 and 13 of the All

Wales Dementia Care Pathway of Standards (Improvement Cymru, 2021).

4. Develop a bank of resources to share information and practical advice at the Universal

level of support, which will be co-produced with people living with dementia and their

carers/supporters, and will offer advice to facilitate supported self-management and

independence. There will also be a focus on supporting people living with dementia to

know how and when to seek direct support from an AHP, whenever needed, in line with

Standard 13 of the All Wales Dementia Care Pathway of Standards (Improvement

Cymru, 2021). The resources may vary in format and include leaflets, postcards,

websites, and videos to suit the accessibility needs of people living with dementia.

Collaborative working with partners will ensure that resources are accessible from the

most appropriate host site.

5. Explore in greater depth and define the role of AHPs in promoting and providing

cognitive prehabilitation in people experiencing cognitive changes.

Outcomes to be achieved by September 2025

• AHPs will be integral as part of regional and national dementia strategies, with their

offer and contribution valued and understood.

• There will be national and regional communication strategies for AHPs working within

dementia care as part of an influencing plan.

• Clear pathways will exist within memory assessment services (MAS), established

within each region, so that people living with dementia and their carers can access

the care, support and expertise of AHPs.

• There will be a bank of AHP-led resources to support population level self-

management to enhance physical, cognitive and psychological wellbeing in dementia.

• A steering group with relevant interest and expertise in exploring and contributing to

cognitive prehabilitation will be established to progress work in this area.

Priority 2: Improvement and Innovation

Developing more robust evidence to demonstrate value of Allied Health Professionals’ care,

support, interventions and emerging practice at universal, targeted and specialist levels of

support

Why is this important?

People living with dementia told us that they want to be able to receive evidence-based,

effective interventions that will enable them to keep doing what matters to them. The recent

literature review of AHP interventions revealed a need for larger scale, high quality research

to strengthen support for approaches that people tell us are valuable to them (Appendix 3

Recent studies have provided a promising indication of the effectiveness of AHP

interventions in relation to individualised rehabilitation that focuses on what is important to

the person (Clare et al., 2019). There is increasing evidence regarding the value and impact

of psychological therapies, including arts therapies, in supporting the wellbeing of people

living with dementia and carers (Deshmukh, Holmes and Cardno, 2018, van der Steen, et

al. 2018). The importance of psychosocial interventions, and therefore the potential value of

AHP approaches, in the management of stress and distress in advanced dementia has also

gained momentum in recent years and thus the evidence base continues to grow (Abraha,

Rimland & Trotta et al., 2017).

A culture of quality improvement, spread and scale approaches where appropriate, and

using meaningful and consistent outcome measures is important to develop practice-based

evidence. Responses from the AHP leader survey (Appendix 4

) suggest a considerable

diversity in outcome measures currently used across Wales. Gathering evidence of impact,

from the perspective of the person living with dementia and their carers, will support future

development of therapy-led services, funding for posts and a shift in culture towards

rehabilitation and enablement. Resources such as the ‘Magic Moments’ storytelling

approach can empower people living with dementia to tell us about their experiences of

accessing care and support, so that we can understand what really matters and what works

(Improvement Cymru, 2021). Connections with the AHP Quality Improvement (QI) Network

and Q Community can support with embedding continuous improvement in practice.

Greater connections with academic institutions, protected time for research activity and

infrastructure to empower clinicians to develop research skills will support with contribution

to the research evidence here in Wales. Increased promotion of clinical-academic AHP

careers will help to embed a culture of continuous improvement and quality.

Call to Action:

1. Continue a focus of improvement and practice development, showcasing examples of

innovative practice from across the AHP community. Development of the AHP Dementia

Improvement Project register will support with sharing of innovation.

Available on request. Please email: HSS.RehabAndAHPs@gov.wales

2. Further scoping work in relation to the focus of improvement and engagement with

research at pre-registration level of AHP training within Higher Education Institutions (HEIs).

3. Strengthen links with local, regional and national networks focused on quality

improvement and research. This may include but is not exclusive to Health and Care

Research Wales, the AHP QI Network, Council for Allied Health Professionals Research

(CAHPR).

4. Explore the Quality Improvement skills, abilities and capabilities within the workforce and

opportunities for Quality Improvement training and learning.

“AHPs can be changemakers, with

their ‘can do’ approach to dementia”

Outcomes to be achieved by September 2025

• A national register of AHP improvement projects in dementia care will be

developed, maintained and eventually shared to aid spread and scale of

approaches.

• AHPs will have the skills, knowledge and confidence to undertake improvement

projects, that evidence the impact of AHP innovation and support further

professional development and learning.

• AHPs will utilise tools within clinical practice to support learning and development,

such as storytelling, case studies, Appreciative Inquiry (Cooperider et al, 2003),

Developing Evidence-Enriched Practice (DEEP) (Andrews et al, 2015), alongside

building the evidence base to demonstrate the value of AHPs.

• There will be a centralised register of emerging research and evidence

undertaken by AHPs in dementia care to support dissemination of knowledge and

building of the evidence base.

Priority 3: Co-production and Collaboration

Working together with people living with dementia, their carers and supporters, and building

relationships across boundaries to achieve integrated, effective care

Why is this important?

People living with dementia and their carers are the experts in their care. Scoping work in

developing the framework has identified that there are excellent examples of co-production

within Allied Health Professional (AHP) teams and services happening all over Wales,

some evidenced here in this framework. Robust and meaningful co-production means that

services truly meet the needs of the community that they support, based on users’

experiences of ‘what good care looks like’ and this parallels the aspirations of Standard

One of the All Wales Dementia Care Pathway of Standards (Improvement Cymru, 2021).

Many AHPs have told us that although they have been keen to engage in co-production

with people with lived experience of dementia, they feel that they do not yet have the skills

or resources to do this in a meaningful way. AHPs have identified that they would like to

develop their skills in this area in order to be part of meaningful co-production that involves

people living with dementia and their carers in equal partnerships, not at a tokenistic level.

“Nothing about us without us” encapsulates the need for services to authentically include

the voice of people living with dementia in every aspect of service design and delivery.

People living with dementia should be involved in decision-making regarding their care.

People living with dementia should be central to the work that AHPs carry out, with services

tailored to their individual needs at that particular time. If a person is not able to engage in

making choices independently, a carer or supporter, relative or someone who knows the

person well should be consulted as an expert in their care. Efforts should also be made to

include people with more advanced dementia using creative methods.

In order for AHPs to deliver care and support that is holistic and effective, integrated, multi-

agency working is the key foundation to building support that is tailored to the person.

People living with dementia, together with clinicians, tell us that there is too often a

disconnect between services across health, social care and third sector organisations. This

causes delays in accessing help, breakdown in communication, and a lack of accountability

and organisation in a person’s care.

Call to Action:

1. All AHPs to cultivate authentic, reciprocal relationships with people living with dementia

and their carers/supporters in order to learn and understand ‘what good co-production looks

like’. This will take place in local spaces, in addition to working with national organisations

to ensure the ‘dementia voice’ is heard in the design, delivery and evaluation of services

provided.

2. AHP Dementia Network for Wales to collate and develop resources and guides regarding

the principles and practical steps needed to facilitate co-production with people living with

dementia and their carers/supporters. Quarterly AHP Dementia Network meetings can be

used as forum to share examples of effective co-production in the development of

interventions and services.

3. Strengthen relationships between services at local, regional and national levels, to

ensure that AHP care and support are integrated and collaborative.

Outcomes to be achieved by September 2025

• People living with dementia and their carers/supporters will be involved in the

design of services, big and small, from initial concept, interviewing of new staff, to

evaluation post-implementation.

• People living with dementia and their carers/supporters will participate in the co-

design and delivery of learning and training opportunities.

• People living with dementia and their carers/supporters will be members of

service groups and strategic planning meetings, at regional and national levels,

meaning that the “Nothing about us without us” value will be meaningfully

practised.

• Resources to support meaningful co-production will be developed and shared by

the AHP Dementia Network for Wales.

“Often we only get to see an Allied Health

Professional when there’s a crisis. We want

to see AHPs as early as possible, so that we

can stay well, and plan for the future”

Priority 4: Leadership and Learning

Developing skilled AHP leaders who can influence and transform dementia care

Why is this important?

Dementia is every AHP’s business. Whilst it is recognised that some AHPs may have more

contact with people living with dementia than others, all AHPs regardless of setting should

apply fundamental principles of person-centred care with an enabling and rights-based

approach.

Consultation with health and social care professionals, together with the AHP Leader

survey results (Appendix 4

), highlighted the variation in both knowledge-based and skilled-

based learning opportunities available to AHPs across Wales in relation to dementia.

People living with dementia and their carers also told us that whilst they had experienced

high quality, person-centred care in some settings, there were also times when care they

received did not align with fundamental principles in dementia care.

The Good Work Framework (Care Council for Wales, 2016) sets out principles to improve

consistency in the development of knowledge and skills needed to support people with

dementia and their carers to live as well as possible. AHPs need to reflect on their own

learning and development needs to ensure that they have the knowledge, skills and

competencies to meet the needs of people living with dementia within their area of work. It

is paramount that AHPs work within robust professional leadership structures, with

appropriate access to supervision and support to develop services, through AHP leadership

that understands the complexity of dementia care and is well-integrated into wider Wales

and UK dementia care networks, transformation and developments.

Engagement also highlighted variation in AHP involvement in learning and training

delivered across the workforce. AHPs have a key role in providing high quality training

regarding person-centred approaches to promoting independence, meaningful activity,

communication, physical health, mobility and emotional wellbeing.

In order for AHP practice in dementia care to continue to evolve, and to demonstrate the

value of the AHP contribution, transformational leadership will be needed to drive forward

change. AHPs can be leaders at all levels of the health and social care system,

championing the rights of people living with dementia and their carers and supporters. The

AHP leader survey highlighted a significant need to further develop senior AHP leadership

in dementia.

AHPs should be supported to develop their leadership skills, to influence change and bring

a collective voice to change the culture of care. Leadership to support others to understand

the rehabilitation and enablement approach to dementia will help to change the deficit-

focused narrative around dementia, and drive transformation that will ultimately enhance

quality of life for those living with dementia and their carers and supporters.

Available on request. Please email: HSS.RehabAndAHPs@gov.wales

Call to Action:

1. Increase AHP leadership representation at a strategic level, including membership in

Local Health Board Dementia Boards, Regional Partnership Boards, and AHP Professional

Collaboratives, to build relationships across agencies with key stakeholders and maximise

the impact of AHPs.

2. Develop regional AHP dementia senior leadership roles to provide clinical leadership and

facilitate sharing of dementia knowledge and approaches from an AHP perspective.

Working at an Influencer Level (Care Council for Wales, 2016), they will share strategic

expertise within a local consultation model, which will help to mitigate regional variation in

AHP service provision.

3. Increase sharing of knowledge and skills from AHPs working within enhanced dementia

services with the wider AHP workforce, to implement the recommendations of the Good

Work Framework. This aligns with the All Wales Dementia Care Pathway of Standards

Standard 17 (Improvement Cymru, 2021).

4. Explore the current provision of learning opportunities for pre-registration AHPs in

relation to brain health, ageing and dementia, to ensure that those entering the workforce

are working at an Informed Level (Care Council for Wales (2016), with the fundamental

skills needed to provide support for people living with dementia. This aligns with the All

Wales Dementia Care Pathway of Standards Standard 17 (Improvement Cymru, 2021).

5. Ensure there are suitable, robust AHP and profession-specific leadership models

supporting all AHPs in dementia care, in order to support safe, effective and best quality

practice and AHP services.

“A service should fit around the person.

The person should not fit into the service”

Outcomes to be achieved by September 2025

• AHPs will have the skills, knowledge and capabilities needed to provide effective,

safe and enabling care for people living with dementia and their

carers/supporters, aligning with requirements set out in the Good Work

Framework (Care Council for Wales, 2016).

• There will be regional AHP Dementia senior leadership roles, strategically placed

to provide clinical leadership.

• There will be benchmarking undertaken to develop an understanding of dementia-

specialist AHP staffing acuity across Wales, including Welsh language provision.

• AHPs will work within robust AHP leadership structures, across the tiered

approach, integrated into multi-professional, cross-agency forums to maximise

the reach and influence of AHP expertise and promotion of a rights-based,

enablement approach to dementia care.

Future directions

This framework defines how Allied Health Professionals (AHPs) in Wales can empower

people living with dementia, their carers and supporters to remain as physically, cognitively

and socially active for as long as possible, to live a life of quality following their dementia

diagnosis. The framework also begins to explore the AHP contribution to brain health and

dementia risk reduction.

It has brought together the voices of people living with dementia and their carers/supporters

at the front and centre, together with health and social care professionals, and third sector

organisations, to explore what best practice looks like in real terms. What is clear is that

excellent work is taking place across Wales, and there is significant passion and drive

within the AHP community to continue to improve standards for people living with dementia,

their carers and supporters.

With the introduction of the All Wales Dementia Care Pathway of Standards, together with

the All Wales Dementia Friendly Hospital Charter, and the Strengthening Provision in

response to COVID-19 report, the impetus is strong for AHPs to work creatively and

collaboratively to achieve the outcomes that matter most to people living with dementia and

their carers and supporters.

This framework provides the evidence, momentum and actions needed to transform AHP

practice in order to deliver care, support and interventions that can enhance quality of life in

dementia. With oversight from the National Consultant AHP Lead for Dementia, further

development will need to explore the impact of delivering the actions of the framework and

a commitment from all partners involved in developing this guidance will be needed to

implement the vision of this framework.

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