Wirral Local Enhanced Service for Dementia

ContactNHS Wirral CCG
Telephone0151 651 0011
AddressOld Market House, Hamilton Street, Birkenhead, Wirral, CH41 5AL

Wirral Local Enhanced Service for DementiaThis sets out Wirral Clinical Commissioning Group’s shared care arrangements for people diagnosed with dementia through a GP Local Enhanced Service for Dementia Care.

Download the Wirral Local Enhanced Service for Dementia


Wirral PCT and Department of Adult Social Services developed a local strategy for Older People with Mental Health Needs. The local strategy built on the development and implementation of a locally agreed dementia pathway. Both the pathway and local strategy identified the need for people to receive care and treatment in the community for as long as possible and reduce the need for unplanned hospital admissions.

In implementing the local strategy, NHS Wirral developed and commissioned a Wirral-wide Memory Assessment Service, together with a range of community-based support services and initiatives.

The Memory Assessment Service (MAS) commenced in October 2010 and is provided by Cheshire & Wirral Partnership NHS Trust (CWP). This followed the decommissioning of the former community Memory Clinic.

The referrals and caseload within the service have continued to increase, which has placed pressure on capacity within and therefore access to the service. NHS Wirral and latterly Wirral CCG have agreed to commission additional capacity to ensure continued access, however it is recognised that the service in its current form is insufficient to meet local current and predicted demand. Therefore alternative models of delivery, including shared care arrangements for monitoring and review with Primary Care are being developed.

GP Local Enhanced Service for Dementia Care

This GP Local Enhanced Service for Dementia Care in 13/14 aims to:

  • increase GP and Practice Nurse knowledge and understanding of the management of patients with dementia, and also of the needs of carers and the support that is available;
  • increase the early recognition and diagnosis of dementia through opportunistic screening (asking patients if they have problems with their memory affecting their daily life when they routinely attend GP/Practice Nurse appointments) and work towards the estimated prevalence for their practice on their dementia register. Practices should use the CANTABMobile App on the iPad or the GPCOG as the preferred assessment option.
  • provide a recall and review system for people who have been transferred back into primary care from the MAS after being initiated and stabilised on Anti Cholinesterase (ACIs) according to the local shared care protocol, or those for whom medication is not appropriate but a six-monthly review has been deemed appropriate by the MAS;
  • share the management of patients with dementia and clarify the role of primary and secondary care, and other stakeholders as appropriate in assessment, diagnosis, medication (initiation, maintenance and decision making around discontinuation of medication), follow on care and end of life care;
  • implement regular medication reviews for patients stable on dementia medication, to be undertaken within primary care. Practices will be able to refer back to the Wirral Memory Assessment service in case of any doubts, side effects or deterioration for which the GPs require specialist input from secondary care;
  • contribute towards the reduction of the waiting time for a memory assessment in the MAS, by implementing the shared care protocol in the GP practices. This will enable the MAS to focus on the increasing demand and more complex cases.
  • provide care closer to home and reduce the number of stable patients being managed in secondary care;
  • provide a holistic package of care to enable more people with dementia and their carers to be managed in primary care where appropriate;
  • enhance physical care and health promotion advice for all patients and carers for people with dementia, especially regarding vascular dementia;
  • ensure patients with dementia and their carers receive the same level of dementia care among all GP practices in Wirral;
  • provide support for patients and carers, via the Dementia Carers Outreach service provided by Alzheimer’s Society, Wirral Branch. WIRED for the Carer Break Programme.


To qualify for payment under this LES, the practice will be required to:

Identification / Assessment

  • undertake investigations/screening as indicated in the Shared Care Protocol and management plans  and investigate any abnormalities to exclude potentially treatable causes prior to referral to Wirral Memory Assessment Service;
  • undertake opportunistic screening especially regarding high risk groups (people with learning disabilities, people who have had a stroke or have a neurological condition such as Parkinson’s disease);
  • maintain accurate and up-to-date dementia QOF registers: ensure all patients with dementia are registered on the practice dementia register and their carers on the carers register.  The practice will signpost carers to available support as appropriate;

Shared Care

  • record the discharge letter received from Wirral Memory Assessment Service and act upon guidance mentioned in the letter;
  • adopt the Shared Care Model including the management of people stable on dementia medication (acetyl-cholinesterase / memantine).
  • undertake a bi-annual review of all patients discharged from the MAS into a shared care arrangement from 1st December 2012 onwards, in line with the pathway and management plans.  It is recommended that one review per year is carried out by a GP, and the follow-up review by a nurse.  However, it is up to each practice to determine the most appropriate clinical solution according to their workforce.  The reviews must be face-to-face;
  • have a system in place to ensure all patients on Anti Cholinesterase (ACIs) / memantine treatment and anti-psychotics are reviewed in line with current shared care prescribing guidelines;
  • continue the prescribing of AChE inhibitor / memantine treatment and adjust the dose as advised by the Memory Assessment Service and in line with NICE clinical guidelines;
  • notify Wirral Memory Assessment Service of any adverse drug reactions, deterioration in condition or any other clinical concerns regarding the patient’s health that can not be managed in Primary Care – a telephone line for advice has been established – 0151 488 7758;
  • a small minority of patients will be discharged into shared care without being on medication, and a six-monthly review schedule has been recommended.  In these cases, the GP will need to determine if a six-monthly review remains appropriate (through face-to-face review of the patient), or if the patient can be stepped down from shared care.
  • Practices will continue to monitor a patient’s cognitive level, as per NICE guidelines, using the MoCA until certain criteria are met:
    • The patient is no longer able to complete this test, due to significant communication difficulties so that they can no longer understand the instructions for the test, or experiencing significant distress as part of the testing process OR
    • The patient’s cognitive level falls below 10/30 on this test

In these cases, the reason for the cessation of the cognitive testing must be recorded, and an overall assessment of the patient’s condition made on the Global Deterioration Scale (GDS)

Training and Education

  • identify a named clinical lead for Dementia, who will be responsible for cascading any relevant information to colleagues in the practice;
  • the Clinical Lead for Dementia will attend one annual educational training course (option to attend training delivered by members of the Wirral Memory Assessment Service, or complete a e-learning module, such as modules available from https://e-lfh.org.uk/projects/dementia/index.html or https://www.scie.org.uk/publications/elearning/dementia/index.asp
  • commit to allow its clinical staff to participate in a programme of professional development to ensure that GPs and practice staff develop expertise and knowledge to manage patients with dementia, and provide carers with essential support information. To support this, the CCG will:

Validation and Payment

Payments under this LES will be paid as follows:

  • A practice will be expected to offer one GP review appointment and a follow-up nurse / GP appointment to each patient discharged into shared care within a twelve-month period.  A payment of £30 per patient will be payable per face-to-face review.  No more than £60 per patient will be paid during a twelve month period. Reviews should be claimed for using the quarterly claim form.
  • Practices must make use of the Read Code and free text in Appendix Four to record each review undertaken under Shared Care Arrangements.  Practices will be selected at random to monitor performance under this LES and to verify payments.
  • Payment is only for patients discharged from Wirral Memory Assessment Service since December 2012 and who receive a review during 2013/14.