Dementia Diagnosis Ambition – Learning from East of England CCGs

This briefing published by the East of England Strategic Clinical Network outlines learning points for achieving the dementia diagnosis ambition from Clinical Commissioning Groups.

Download Dementia Diagnosis Ambition – Learning from East of England CCGs


  • Increased awareness with a Community Mobilisation Steering Group – raising profile of benefits of early diagnosis with a range of stakeholders to spread the word within the community to increase people coming forward
  • With a range of stakeholders including Adult Social Care, MH Trust, Alzheimer’s Society, District General Hospital and the general public during Dementia Awareness Week (DAW) (18th –24th May 2015)


  • Monthly system wide newsletter – two of which have been dedicated to dementia
  • Monthly communication to practices outlining the CCG position and gap to diagnosis ambition
  • Reminders to practices of the available tools (including Dementia Quality Toolkit and SUS Data)
  • Regular communication with primary care
  • Pack of useful information sent to practices (including Dementia Revealed, Brief Pragmatic
  • Resource for GPs and a laminated guide to all dementia services in the area including post diagnostic support

Care Homes

  • Validation Scheme – Scoping of patients in care homes, diagnosis by trained dementia nurse, validation of diagnosis by clinician and updating practice register
  • Care Home Enhanced Service
  • Care home, memory clinic and associated third sector pathway
  • GP diagnosis in care homes within their area

Education / Training

  • Dementia workshops through time to learn events with GPs
  • Dementia talks at Local Clinical Group Meetings
  • Talks to GPs from Dr Sunil Gupta on the benefits of early diagnosis
  • Community dementia nurse training via Anglia Ruskin University to support severe diagnosis in memory clinics and care homes
  • Dementia training for clinical and non clinical staff across the CCG

Incentives, Monitoring, New Models

  • Dementia Enhanced Service
  • Care Home Enhanced Service
  • Contract KPI with MH provider for 95% RTT within 6 weeks
  • Close and consistent monitoring by the CCG
  • Shared care protocol to support the diagnosis in primary care
  • Computer system prompts for at risk patients
  • Triangulate the list of patients with the LD provider and cross reference to QOF register


  • Mental Health Clinical Lead drive and determination
  • CCG board commitment
  • Clinical leadership and engagement from CCG reinforcing the importance of timely diagnosis and the benefits for patients and carers
    Wider stakeholder support via the local health and social care economy and networks i.e. Dementia Strategy Group.
    Dedicated project worked within CCG to coordinate the approach

Memory Assessment Service

  • Commissioned increased capacity to ensure timely response to referrals
  • Commissioned additional support from Alzheimer’s Society in MAS clinics and GPs
  • Focus on MAS redesign to improve variation in access and performance
  • Partnership working and challenge with MH provider to ensure effective performance of MAS

Targeted Support

  • To facilitate the practices in updating their records and embedding robust processes
  • For those practices without capacity to do the harmonisation work it was done by the CCGs
  • Medicines Management Technicians and the records were reviewed by the practice.
  • To a small group of practices with the greatest gap and lowest diagnosis rate – offering bespoke on site support from a dedicated clinician
  • Providing support and advice direct to practices
  • GP associate visited every practice to discuss the benefits and issues around dementia diagnosis