Closer to home memory assessment: reaching out to rural communities in Buckinghamshire

ContactMr Ojalae Jenkins, Joint Commissioning Manager, NHS Buckinghamshire / Buckinghamshire County Council
Telephone01296 383 183
AddressBuckinghamshire County Council, Walton Street, Aylesbury, Buckinghamshire, HP20 1YU

This project aims to adopt the Gnosall primary care based memory assessment approach to improve dementia diagnosis in harder to reach communities in Buckinghamshire.

This project will create a primary care based memory assessment function that will focus on providing;

  • Improved access for hard to reach groups
  • Assessment closer to home within familiar surroundings
  • Rapid referral, diagnosis and post diagnosis support
  • Training for GP practice teams on identifying dementia
  • Increased awareness of dementia within wider community health teams and care providers


Short term:

  • To increase the number of people with a diagnosis of dementia
  • To provide a quicker service from suspected dementia to diagnosis
  • To improve access to services for those in harder to reach communities
  • To create a community of practice ‘peer to peer’ trainers

Longer term:

  • To reduce overall systems costs for dementia through early diagnosis (specifically social care costs, based on Whole System Partnership modeling)
  • To strengthen the role of general practice across the county in the identification, assessment and diagnosis of dementia

Learning from elsewhere

The Gnosall dementia service is a primary care based older people’s mental health service that is designed to improve access, reduce diagnosis time and develop value-added interventions to improve care of patients with dementia.   Based in a rural, primary care setting, outreach consultant-led clinics provide rapid diagnosis and cost-effective medical care.

Patients at risk or in the early stages are identified through existing ‘Quality and Outcomes Framework’ disease databases.  These diseases are associated with an increased risk in developing dementia. The staff within the practice proactively look for changes in cognition and mood in this group of patients. In addition to this cohort, any patient who is exhibiting signs of altered cognition or mood will be referred into the service.

Patients identified are referred to the dementia support worker for initial assessment. The dementia support worker is a member of staff from the Alzheimer’s Society. They bring experience and knowledge to the primary health care team and a befriending, single point of contact for patients.

The support worker visits the patient at home within two weeks, with their relative or carer present. A social and medical history is taken and an assessment made using the clock test, general practice assessment of cognition (GPCOG) and brief assessment schedule depression cards (BASDEC) screening tools. Patients are seen within a month, by the consultant old age psychiatrist at the practice or at home. The patient and carer will be given details of what to expect at their appointment and the contact details of the support worker for advice or support.

The support worker will present the patient to the consultant who will undertake an examination of the patient’s physical and mental state taking into account relatives’ or carers’ observations. The consultant has access to all the patient’s medical records held in the practice, which makes it possible to generate a more holistic picture of the patient’s health and wellbeing.

The consultant devises a care plan, including recommendations for managing related diseases, with the input of the patient and carer, the primary care team and social services. The consultant initiates any specific dementia drugs and sets out a shared care protocol for ongoing management. Copies of the care plan are sent to the patient and all relevant parties and scanned onto the patient’s notes. Follow up appointments occur according to recommendations by the consultant or in response to changes in the patient’s circumstances. Patients and carers are asked for their experience of the service via a questionnaire. Results are extremely positive, demonstrating that they feel supported by the team and confident in the service.

Anticipiated outcomes

  • Increased diagnostic rate; from 40% to 70% by 2015
  • Increased response time of 6 weeks from identification to diagnosis
  • A reduction in general hospital bed days for people with dementia (informed by Whole System Partnership modeling)
  • Embedding of a new Buckinghamshire wide primary care dementia protocol
  • Increased awareness and understanding of dementia within primary care teams
  • Increase number of people with dementia being prescribed the right medication and a reduction in the use of antipsychotic medication.
  • A community of practice staff who can offer peer to peer training on early identification, assessment and diagnosis of dementia.