Collaborative dementia care in Oxfordshire

ContactFunmi Durodola, Service Development Manager, Oxfordshire CCG
Telephone01865 334603
AddressJubilee House, 5510 John Smith Drive, Oxford Business Park South, Cowley, Oxford, OX4 2LH

This project aims to develop a more user-friendly care pathway for people living with dementia in Oxfordshire by providing easier access to assessment for early diagnosis and support within primary care settings.

Oxfordshire’s population of 624,000 represents 4.3% of South of England population of 14.2 million. This county faces a major demographic challenge with the number of people aged 85+ set to double over the next 15 years – a rise in prevalence of Dementia by 31%1,2. The current prevalence is 7,086, highest in our rural areas with West Oxfordshire being highest.

Current challenges include:

  • Only 37.8% incidence is currently recorded. Need to meet targets set for diagnosis of by both Oxfordshire Joint Health and Wellbeing Board (50% by end March 2013) as well as nationally (70%).
  • Our current pathway relies entirely on diagnosis within secondary care setting. This is often stigmatizing, some distance from the homes of people with dementia and their carers, and also costly.
  • Most follow up takes place in secondary care settings as well.
  • Patients do not consistently receive holistic care (encompassing their co-morbid states) within the current arrangement.


  • Increased rate of timely diagnosis and with corresponding support plans.
  • People get the same quality of specialist diagnosis and follow up in their familiar primary care setting.
  • More holistic care planning for people with dementia.
  • Better dementia awareness and on-the-job learning for GPs and their staff to build capacity for diagnosis by developing greater primary care input into the diagnostic pathway.

Learning from elsewhere

The Gnosall Model (Stafford)  of commissioning memory services has been successful in providing secondary care expertise within primary care. Their recognition rate has risen from under 10% to 100% and significant amounts of money saved by reducing admissions. Patient and carer satisfaction is high as well. Our project will:

  • Develop joint Primary and Secondary Care clinics sited initially in one practice, then rolled out to other practices in that locality.
  • Ensure an holistic care plan is developed for each patient new diagnosed which will help both the management of their dementia but also any co-morbid Long Term Conditions (LTCs)
  • Ensure appropriate post-diagnosis services are available locally
  • Develop diagnostic capacity by increasing the role of Primary Care in the diagnostic pathway
  • Explore developing the role of an Elderly Care Facilitator (as per the Gnosall Surgery model)

Anticipated outcomes

Our overarching outcome is to achieve a more user-friendly dementia pathway and easier access to assessment for early diagnosis and support services with primary care playing a bigger role in the treatment and care of patients with dementia thus increasing the rate of diagnosis. The impact: Holistic care plan, avoidance and reduction in hospital admissions, slowdown of the progression to higher levels of care need and delay in the length of time between each stage.

  • •Increase in the number of people who have a memory assessment, measured each quarter of year 1 of the project.
  • Increase  in the total number of  people  diagnosed  with  dementia  per  practice, measured quarterly in year 1.
  • Increasing awareness amongst  GPs  and  practice  staff  of  the  benefits of  earlier diagnosis of dementia. Measured through a baseline and a six month analogue scale reported by GPs and practice staff
  • Increasing the capacity for diagnosing dementia. Measured through a baseline and a six month report.
  • Diagnosing dementia earlier in their disease journey and so offering support and signposting earlier. Measured through the increased activity of dementia advisors.
  • Earlier support for carers and better quality of life. Measured through a baseline analogue scale measure of how well carers feel supported and anticipating an increase in the same measure in 12 months’ time.
  • Financial savings through reduction in acute admissions and excess bed days.

Progress update

  • Provider and primary care sign-off on the diagnosis protocol for the primary Care Diagnosis and Management of Cognitive Impairment and Dementia
  • Supporting prescribing protocol has been approved by the Area Prescribing Committee, outlining the necessary information and guidance to support clinicians in the appropriate prescribing of Acetylcholinesterase (AChE) Inhibitors in line the South West Oxfordshire Collaborative Project.
  • Developed training materials to support participating practice staff.
  • The mechanism for monitoring and evaluating the pilot project are in place, and will be reported on periodically throughout the pilot.
  • Preparing the final content for a communications pack to the support services identified.