Specialist Link Nurses in Surrey Downs

ContactDr Sen Kallumpuram, Surrey and Borders Partnership NHS Foundation Trust
AddressNHS Surrey Downs CCG, Pascal Place, Randalls Way, Leatherhead, Surrey, KT22 7TW

This project aims to increase diagnosis rates in the Surrey Downs community by adopting an innovative approach of using Specialist Link Nurses.

Specialist Link Nurses will help identify and screen more patients thereby contributing to improved rates of diagnosis. Nurses trained in dementia care will be introduced into the community to identify patients at risk of dementia through the GP practices Quality and Outcomes Framework (QOF) age and disease registers.

Link nurses are highly qualified nurses and bring with them experience of working with people with dementia (PWD). A similar pilot project undertaken in South West of Kent CCG demonstrated such encouraging results that it was embedded into mainstream service and has developed further.

As dementia often co-exists with other conditions, nurses use the disease registers to invite patients for cognitive screening using validated screening tools, e.g. the MINICOG and Functional Activities Questionnaire (examples in appendix) in the primary care setting. Those identified with possible dementia will have further investigations and will be referred to local community based memory clinics, in Surrey County Council Wellbeing Centres.

The Wellbeing Centres provide a base where ongoing support can be given to someone with a diagnosis of dementia. They will provide premises for the community based memory clinics. Consultant Psychiatrist-led clinical teams from our project partner, Surrey and Borders Partnership NHS Foundation Trust will diagnose patients and pre/post diagnosis support and management will be offered by the link nurse. Patients who do not wish to receive a formal diagnosis will still receive support from the link nurse as Dementia Navigators will only support people to get a formal diagnosis of dementia. They do not provide ongoing support to someone without a formal diagnosis.

Specialist Link Nurses will establish a dynamic relationship with GP practices, attending practice meetings, updating practices on patients who have been screened, updating patient records and documenting discussions that have taken place regarding future planning including end of life care and preferred place of death, as well as updating the QOF register for dementia. There is no current service provision for this in Surrey Downs GP practices.

GPs and primary healthcare teams will be supported by two educational events annually. These events will be used as a platform to initially launch the link nurses and their roles, improve awareness of dementia, provide updates on diagnosis and management of dementia as well as discuss end of life care issues surrounding patients with dementia.


  • Introduce the Link Nurse role to identify people at risk of dementia (detection) on GP practice QOF registers and improve the diagnosis of dementia at an earlier stage in the community setting.
  • Provide support before and after diagnosis, and facilitate discussions with the PWD and their carer or families about choices regarding treatment and end of life care and promote crisis prevention by helping draw up care plans, and signpost to other services as appropriate.
  • Increase education and awareness of dementia amongst GPs and primary healthcare teams so that they feel well supported and are informed providers of care to people with dementia.
  • Fulfill Sir Ian’s challenge and those identified in the 5 year strategy for dementia by NHS Surrey and Surrey County Council to improve diagnosis rates from 43% to 60% in the first year.
  • Focus on two of the three key areas in the 2009 National Dementia Strategy.
  • Ensure that services all adhere to the 10 NICE quality standards of care in dementia. Help to achieve the NHS Surrey Downs CCG Quality Innovation Prevention and Productivity (QIPP) plan of reducing unscheduled admissions and reducing inappropriate lengths of stay in hospital – aims shared by patients in the 5 year Surrey dementia strategy.

Anticipated outcomes

  1. Screening: Increase the number of patients being screened for dementia, i.e. identifying the problem. The link nurse will aim to screen at least 75% of patients identified through chronic disease registers as being at risk of dementia each quarter. A log will be kept of patients screened.
  2. Diagnosis: This will lead to more patients being diagnosed with dementia at an earlier stage. An earlier diagnosis of dementia will be beneficial for patients because they will get treatment earlier and they and their carers will receive support, signposting etc at an earlier stage.
  3. Education: Meeting the Link Nurse, receiving information about dementia, meeting the navigators, and attending the Wellbeing centre which will be a community hub will educate the patient and carer about local services available to support people with dementia. The increase in attendance to the Wellbeing centre will be a measure of how many more patients and carers are accessing the resources available to them, this data will be measured quarterly. An annual patient and carer satisfaction survey will be undertaken to inform and commission future service developments.
  4. Support: This includes dementia navigators, carer support programmes and telecare. The link nurse will provide both pre and post diagnosis support also to the patient and carer, and signpost to Alzheimer’s Society Dementia Navigators for further non clinical input.
  5. Planning: Discussions about end of life care can take place at an earlier stage and decisions about treatment and preferred place of death can be made. The link nurse will maintain update the patient’s primary care record and document all discussions about future care provision, end of life decisions regarding treatment and preferred place of death.

In addition,

  • It will also enhance the primary healthcare team knowledge of dementia and improve management of people with memory loss in primary care by supporting primary healthcare team education
  • There will be additional financial savings that will accrue to the wider health economy from the reduced costs of informal and social care
  • NHS Surrey Downs CCG QIPP plans include reducing unscheduled admissions and increasing the number of people dying outside of the hospital if they so wish. The national hospital CQUIN for dementia aims to improve the detection of cognitive problems and identifies patients who need to be followed up in a memory clinic to assess them further after discharge. This project means that patients will not be lost to follow up once discharged from hospital. Link nurses will therefore support this new cohort of patients as well.

Progress update

Link practitioner project to improve dementia diagnosis rates at an earlier stage in at risk populations.

The project is already reaching all practices in the CCG, but could expand the age range of patents being assessed.

Project management commenced in April 2013, and 2 of the 4 link practitioners ave been recruited and have been working since July 2013. Patients aged 75-80 with cardiovascular or neurological risk factors are sent a letter to invite them to have a memory assessment with a link practitioner, at their local GP surgery. So far, over 600 letters have been sent, with 300 patients having been assessed.

It is too early to say which of these are undiagnosed with dementia. The project as been very well received by patients and GPs locally. Local media outlets eg newspapers and radio have interviewed the project lead and public awareness events have been held. GP education events have been organised with a lot of interest. Next steps are to recruit the remaining link practitioners to ensure the consultant teams are supported in secondary care.

2 thoughts on “Specialist Link Nurses in Surrey Downs

  1. Dr Sen Kallumpuram

    I lead this Dementia Challenge Project after Dr Khan left the project. We have now completed the project, we are in the process of analysing the results. The project has definitely helped increasing the rate of diagnosis of people with dementia in Surrey Downs area. It has also helped in identifying dementia early on thus helping the patients and carers to receive treatment and access other support services.

    1. Rowan Purdy Post author

      Hi Sen,

      Thanks for getting in touch and providing an update on the project. I have updated the contact information, replacing Dr Khan’s contact details with your own.

      Rowan, Editor, Dementia Partnerships

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