Dementia: Good Care Planning

This guide is aimed at primary care and commissioners, particularly GPs, who provide care plan reviews. It is designed to help improve care planning in dementia by supporting a standardised approach, highlighting good practice, ensuring alignment with relevant crosscondition care plans and help to reduce local variation in the process.

Download Dementia: Good Care Planning – information for primary care and commissioners

Care planning is a priority for NHS England and plays a vital role in improving the quality of mental health and dementia services. NHS England is committed to:

  • supporting the delivery of the recommendations in the ‘Prime Minister’s challenge on dementia 2020’ including improving the ‘quality of post- diagnosis treatment and support for people with dementia and their carers’; and
  • leading ‘a step change in the NHS in preventing ill health and supporting people to live healthier lives’, a key priority in the NHS England Mandate.

Care planning is a crucial element in delivering improved care for all people living with dementia, and supporting their families and carers. This has been brought into sharp focus through the CCG Improvement and Assessment Framework which includes indicators for dementia diagnosis and post diagnostic support.

This document has been developed with input from a diverse range of people living with dementia, their carers and health and social care professionals, to offer a quality assurance framework to enable more effective care planning, personalised and responsive to needs and preferences.

There is an urgent need to ensure every person who has dementia has an individual care plan and to aim for, wherever possible, greater integration with support plans in other areas such as social services.

The information provided in this resource document highlights the key characteristics of a person-centred dementia care plan and is aimed at primary care and commissioners who provide care plan reviews as part of the Quality Outcomes Framework (QOF) incentive scheme in primary care.

Improved care planning in dementia services will be achieved by:

  • supporting a standardised approach reducing unwarranted local variation in process or outcomes;
  • promoting equality and tackling health inequalities;
  • ensuring alignment with relevant cross condition care plans such as diabetes; and
  • drawing on examples of good practice around the country.

This document covers:

  • The components which constitute the minimum information to be included in a good care plan.
  • Examples of dementia care plans that are already being used at a local level.
  • Considerations for computer systems available in primary care to create a dementia care plan and make appropriate links to care plans for correlated conditions.

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