Dementia support workers in Plymouth

ContactRachel Silcock, Commissioning Officer
Telephone01752 307176
AddressPlymouth City Council, Windsor House, Plymouth, PL6 5UF

This project will recruit 5 Dementia support workers to improve the support, information and co-ordination of services for people living with dementia in Plymouth.

There will be 1 Dementia support worker in each locality team in Plymouth, based on a case load of 1:200, current prevalence and the service being provided to 80% of identified cases.

The Dementia support workers will also act as brokers for people with personal budgets and this mechanism will therefore be in place to support Choice and Control in personal health budgets by 2014. A broker role can be essential to support access to personal budgets for people who find decision making and managing finances difficult.

In addition, the Dementia support workers will contribute to raising local public awareness about dementia. They will also link closely with the ‘out and about’ workers as part of Plymouth’s dementia friendly communities strategy, supporting people with dementia to establish social and support networks to promote wellbeing and allow people with dementia to live well.

Dementia support workers will also work with GP’s and memory clinic nurses attached to the locality to increase awareness in practice communities, rates of diagnosis and support case finding in primary care.


Community dementia support has been identified as ‘a potentially crucial and powerful tool’. It offers the potential to improve services yet reduce both health and social care costs per patient; it provides visible post-diagnosis care to reduce perceived therapeutic nihilism; it can help service users (both people with dementia and their carer and/or families) access what they need at the right time for them; and above all it offers patients and carers the support that they need to remain in their chosen environment for longer.’ An Evaluation of Dementia Support Roles, Southwest Dementia Partnership 2011

Current health and social care services normally discharge individuals once the case is stable and the care package is being delivered. This is almost always perceived negatively by people with dementia and their carers, who, faced with a serious illness where there is inevitable long term decline and increase in dependency, want to feel there is continuing support available to them when they need it. This support needs to be complementary to other parts of the care pathway – not providing intensive case management but operating as a single identifiable point of contact with knowledge of and direct access to the whole range of local services available.


The Support Worker posts will:

  • Provide timely information and support to people on diagnosis
  • Act as a broker to support the person in spending their Personal Budget
  • Link people with the right services when they need them
  • Ensure there is co-ordination across all aspects of the pathway
  • Support smooth discharge from hospital by linking the person into services such as the Red Cross
  • Link to the Out and About ‘befriending’ service
  • Co-ordinate training to aid identification of dementia in community settings
  • Link with Plymouth City Council and localities in Plymouth to support Plymouth as a Dementia Friendly City
  • Raise awareness about dementia with public
  • Support GP’s and memory nurses with identification of people with dementia
  • Work closely with locality memory nurses

Anticipated outcomes

This project would result in people with dementia being able to say:

  • I feel part of a community and feel inspired to give something back
  • I know what I can do to help myself and who else can help me
  • I understand so I make good decisions and provide for future decision making
  • I was diagnosed early

Other outcomes include:

  • Improved patient and carer satisfaction – by enabling choice and control
  • Improved health and well-being of people living with dementia and their carers
  • Improved quality of care
  • Increased recorded prevalence in primary care databases
  • Reduced health inequalities and social exclusion
  • Reduced stigma

Progress update

The Dementia Support Worker Service in Plymouth is delivered by the Alzheimer’s Society and consists of 5 DSWs who are co-located within the City’s Memory Service. As part of the Community Dementia Pathway, those patients who are maintained on ACI medications are reviewed annually and at the nurse led clinic they are referred directly to a Dementia Support Worker. Other patients who are worried about receiving a diagnosis or who have just recieved a diagnosis can also be referred to the service or can self-refer. The service can offer advice, support, information about services and benefits and signpost to services such as befriending or carers support. The service aims to support up to 1000 people with dementia and carers by the end of March 2014.