Discussion
dementia
This translational implementation project is one of few focusing on provision of home-based rehabilitative interventions for people with dementia. We aimed to develop a foundation for wider roll-out of an evidence-based personalised cognitive rehabilitation intervention for people with mild-to-moderate dementia. The implementation in community health and social care services in England and Wales was partially disrupted due to the COVID-19 pandemic, but six NHS organisations completed at least half of the 12-month implementation period. All six developed a small group of practitioners who successfully provided the intervention, although none reached their full targets for either the number of practitioners delivering, or the number of service users receiving, the intervention. The main barriers encountered were organisational, and the commitment of the managers and clinical leads who championed the intervention was key in overcoming or mitigating these. When delivered as part of routine services by trained NHS practitioners, mainly OTs, the intervention appeared at least as effective as under trial conditions. The degree of improvement (4.20 points for people with dementia, 4.37 for carers and 4.80 for practitioners) was greater than that seen in the GREAT trial where the corresponding indicators were 2.89, 3.17 and 3.61 points respectively [According to a scoping review, implementation initiatives in dementia care remain relatively limited [As capability to implement an intervention will be reduced if it is perceived or experienced as too complex, adaptations are likely to be needed during the translation phase [Making rehabilitative interventions for people with dementia and carers widely available requires sufficient suitably trained and well-supported practitioners. Our findings show that practitioners respond positively to the opportunity to learn about and provide evidence-based interventions that they consider helpful to people living with dementia, consistent with findings from other programmes [In our study as in others, and according to a scoping review not unusually for implementation studies in dementia care [Our study has several limitations. We proposed to explore implementation in three different types of community-based organisations but were only able to evaluate implementation in NHS services. Therefore, further work is needed to establish how the intervention could be integrated into other types of services and delivered by different staff groups. The reach of the implementation was curtailed by the COVID-19 pandemic, meaning that numbers were smaller than anticipated, and limiting the extent to which we could build on learning from Wave 1 during Wave 2. Some limitations in the estimation of CR costs should be noted. Supervision time was assumed to stay the same with the addition of a new treatment approach, supervisors were assumed not to require additional training themselves, and we assumed that there were no costs to organisations of accessing foundation-level training. These assumptions could contribute to underestimating the costs of CR. However, base-case estimates were similar to those reported in the GREAT trial which included costs of CR-specific specialist supervision. Furthermore, estimation of costs relates to the NHS setting and costs might vary in other service contexts. A final comment relates to the dilemma inherent in researching implementation in real-world settings. Some studies report implementation projects conducted using randomised trial designs [Involvement of people with dementia and carers was another strength of the study. The GREAT CR intervention has been developed over several years with involvement of people living with dementia and their families at each stage, from initial single case experimental designs through small pilot RCTs to the large GREAT trial. For this small-scale implementation project leading on from the main trial we involved two people with dementia as part of the study leadership team; they were co-applicants on the grant and part of the project management group, and they contributed in important ways. They helped with explaining GREAT CR to potential participants in an accessible way and made sure resources such as handouts and evaluation questionnaires were easy to use. Our funder linked three carers from its group of research volunteers with the project and they met with us regularly; their perspective helped to shape the evaluation and think about how the approach could be shared more widely. As the project progressed, we involved a co-production group of nine people living with dementia who took the time to understand GREAT CR, reflected on it in the light of their own experiences, and then worked to create the My Life, My Goals self-management resource [