Leading models of dementia care highlighted to inspire

Three leading models of how to care for people with dementia are being flagged up to the NHS in a bid to improve patient services by sharing learning.

Thousands of people are benefiting from the thriving schemes at Gnosall, Northumberland, and Rotherham and Doncaster and are highlighted in a new report out today.

Patient benefits include: 100 per cent appointment attendance rates, minimal delays, reduced A&E care, less use of mental health services, reduction of fear and stigma, accessibility, choice, specialist tests close to home, only giving information once and having clear agreed care plans.

Professor Alistair Burns, NHS England’s National Clinical Director for Dementia, visited ten per cent of Clinical Commissioning Groups (CCGs) in England to discuss their dementia programmes and see what help was needed before commissioning the report.

He said: “Meeting the dedicated workers on the frontline of dementia care who cope fantastically well in often challenging circumstances was an enormous pleasure.

“It became clear talking to everyone from the patients to the psychiatrist to the GP practice managers and the support workers that what CCGs would like is a detailed information about alternative models being used successfully so they could look at where they could change or innovate.

“The three examples we highlight show a variety of the challenges and successes for three thriving models already working well in the community.

“We have an ambition for England to be the best country in the world for dementia care and in giving support for people and their families and I’m dedicated to working towards this aim.”

This report present indicative costs for three models including:

  • benefits for patients and carers
  • key messages and considerations about developing the service
  • giving good insights into how a local CCG might approach a review of their local service with an aim to making improvements in their current practice.

Model one is the memory service at Gnosall Surgery in Stafford where there is a population of 8,000 – an eighth of whom are over 65. They run a primary care managed service with primary outreach and bring specialist consultant psychiatry into the GP surgery sharing patient responsibility between GP and consultant.

The GP conducts an initial review and the patient is then seen at the monthly memory clinic at Gnosall Health Centre.

The elder care facilitator is the key to the scheme as they have close patient contact and help reduce A&E admissions and non-attendance. The scheme costs around £396 per patient per year.

Model two is the Northumberland, Tyne and Wear NHSFT Memory Protection Service (MPS) providing for 84,000 people.

They have a single point of access manned by nurse practitioner duty workers who respond and direct patients and carers. A nurse will do initial tests then the patient sees the nurse and the consultant and continues for tests if needed at the hospital.

The benefits to the scheme are that anyone can call for advice and support and it is available through a single number. There is choice about where the person can be assessed, specialist tests are provided close to home and an education package are available for both patient and carer to help them come to terms with diagnosis. The evidence shows people who attend the group adjust ‘fantastically well’. It costs £877 per patient per year without the education cost.

Model three shows Rotherham, Doncaster and South Humber NHS FT, an entirely specialist led memory service by the local community and mental health provider RDaSH delivered to 50,000 over 65s.

The service has a personalised approach and a single point of access (SPA), taking referrals from GPs who are expected to have carried out some screening and tests before a patient is referred. The patient is referred from the SPA to the Memory Service or the Community Mental Health Team for further investigations and treatment.

They are contacted on the same day and seen in the memory service by a nurse and consultant in the next available clinic within 28 days.

Costing per patient per year is £491 and the main benefits are patients are only asked to give their information once, there is a clear agreed care plan, they have fast access to specialist services and there is continuing advice and support.

Read the full picture of how each service works.


  1. L Tomlinson says:

    This lacks the opportunity to find a solution by not including a neurology element.
    A specialist consultant in psychiatry is all very well is good in theory but has been found to be seriously lacking in both the John Radcliffe Oxford and The Abingdon Hospital Memory Department.
    The first step should be to look for a cause of the memory problem which psychiatrist fail to do in Oxfordshire.

  2. Ann Tomline says:

    These ways of helping a carer of a loved one with Dementia sound great. We lack anything like that in Oxford. My husband was seen at the Mind clinic then after 2 sessions it is up to our doctor to help ,which is not really possible with all the other things she has to do. I feel very much on my own and have family to help ,but wonder how others cope. My main problem is that the” POWERS THAT BE” forget that everyone is different and what suits one person with memory problems may not suit another, we need flexible help.
    Thank you for reading this

  3. Sue Smith says:

    Glad to see there is some places putting forward plans to help people with dementia. Working GP’s Surgery/ specialist consultant psychiatry into the GP surgery and other services such as screening as this seems to be a step forward in helping patients and carers.