Enhancing the early diagnosis of dementia across East Berkshire

ContactMarianne Hiley, Project Manager, Windsor Ascot and Maidenhead CCG
Telephone01753 636412
AddressKing Edward VII Hospital, St Leonard’s Road, Windsor, Berkshire, SL4 3DP

This project aims to improve the early diagnosis of dementia by increasing the number of initial screening assessments and raising awareness about the benefits of assessment and early diagnosis as part of an overarching Aging Well campaign across East Berkshire.

Most recent Public Health statistics for East  Berkshire indicates a growth of people over the age of 65 with dementia to grow from 3520 in 2012 to 6109 in 2030.  For WAM CCG in particular,the estimated increase in adults over the age  of 65 with dementia will grow from 1724 in 2012 to 3045 in 2030.   However, East Berkshire as a whole and Windsor Ascot and Maidenhead CCG in particular are lower quartile performers against current measures of early diagnosis of dementia across South Central region so the underlying rate may be much higher.

The vital importance of rising to this potential increase by implementing a consistent programme of early dementia screening is recognized by East Berkshire CCGs.  A number of initiatives targeting this issue will be undertaken across the Berkshire CCG Federation to target different stakeholder groups and service access pathways. In particular, increasing diagnosis and  management of dementia in Care Homes is an area of significant concern and will be part of a sister project to the one described below.

The awareness and education programme will be targeted across existing community based social activities eg lunch clubs, health and fitness centres, social networks and hobby groups etc- within which the messages promoting early diagnosis and leading positive lives after diagnosis are  included.

Practice-based Patient Participation Groups will play an important role in supporting both the in­ practice clinical assessment opportunities as well as the design and support of the case study/education programme that is tailored to their locality and patient needs.

Learning from elsewhere

Our approach has been informed by evidence and learning from Plymouth CCG, the Newquay integrated dementia care pathway, Buckinghamshire GP dementia engagement programme and West Berkshire dementia strategy in community based services. This includes:

  • Maximising the use of existing points of contact and assessment opportunities with patients- conducted by trained health professionals within each practice who are seeing patients (and carers) for a range of other on-going treatments and reviews.
  • The programme aims to manage the growth in support services associated with increased diagnosis rates in a staged, progressive and sustainable programme- rather than developing unmanageable peaks and troughs of service demand and supply.


  • Increase the number of MCI diagnoses, from which we will
  • Increase dementia identification rates, at an  earlier stage of development
  • Increase planned investment to promote patient independence and maintaining function through memory clinics and other support services.

Anticipated outcomes

  • Greater awareness of dementia and benefits of early diagnosis (via PPG group feedback)
  • Improved prescribing for dementia sufferers
  •  Continued independence and capability (measured at Memory Clinics)
  •  Increased attendance /adoption of healthy living/aging activities offered by  local authority

Progress update

This has been a great opportunity to raise the profile of dementia issues across WAM CCG which has a significant older population and a high level of underreporting and diagnosis across all member practices prior to the start of the project.

A 6 month development opportunity for a new GP to lead the full implmentation of the project across all CCG member practices, with a pathway redesign on how to expand the memory clinic services has been defined. The post is jointly funded/mentored by the Oxford Deanery and WAMCCG Sept 2013 – March 2014.