Build capacity and support in the community
Questions to consider
- what do people with dementia, and their carers/families need, to live well?
- how can the needs of people living with dementia be better understood, and ‘mainstreamed’?
- what are the commissioning opportunities?
- what is the role of the GP and primary health care team?
DRIVER: Local strategic leadership
| Actions | Resources | Examples |
| Engage with local authority public health, and Health and Wellbeing Boards to review prevalence of dementia and trajectories for increase. Consider implications of this changing profile, over time. Undertake a needs assessment for the current and future population with dementia.
Ensure that the needs of vulnerable older adults are reflected in local planning strategies (supported housing; transport; health; social care, residential and nursing care; carers’ strategies; carers’ services). |
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| Promote dementia friendly communities to tackle stigma, raise awareness, and promote opportunities for people living with dementia to live well. |
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DRIVER: Appropriate treatment, care and support post-diagnosis
| Actions | Resources | Examples |
With stakeholders, review local strategies and care pathway(s) to identify range of support required at different stages and steps, and inform local strategies. For example,
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DRIVER: Recognition and support in primary care
| Actions | Resources | Examples |
| Ensure effective training is in place for GPs and primary health care teams to ensure they have the competences required to recognise memory problems; undertake a basic dementia screen; make a diagnosis of dementia (moderate-severe stage); and refer to specialist memory assessment services where indicated. |
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| Engage with deaneries to promote access to training and education for pre- and post-registration medical staff, including GPs. | ||
| Ensure each General Practice has a named clinical lead, or champion for dementia. | ||
| Promote and facilitate networking between dementia clinical leads / champions. | ||
| Work with primary care commissioners to ensure that standards of care and support are in place in primary care for people who have a diagnosis of dementia, and their carers/families – both for those living at home, or in care homes. | ||
| Work with general practices to ensure that the case management role of the general practitioner is recognised and effective. | ||
| Facilitate the identification of learning and development needs within general practice, and support local improvement plans. | ||
| Promote awareness and understanding of the role of health and social care, the voluntary and community sector, and the independent sector in supporting people living with dementia in the community, and in care homes. |
DRIVER: Carers support
| Actions | Resources | Examples |
| Ensure carers have timely access to carers’ assessments, flexible respite, carer’s breaks, education, single point of contact 24/7. |
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| Ensure carers are signposted to social care to access Carers’ Assessments (Carers Recognition and Support Act, date) | ||
| Capture feedback and outcomes from carers of people living with dementia, in order to establish quality of experience and standards of care. Use this information to inform local service improvement and (re) design. | ||
| Ensure carers receive regular health checks, and engage with health promotion opportunities. |
DRIVER: A skilled, compassionate workforce
| Actions | Resources | Examples |
| Consider range of relevant service contracts, and build in to contracts standards for staff competence in working with people living with dementia |
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DRIVER: Timely, accessible information
| Actions | Resources | Examples |
| Ensure patients and carers/families have access to a range of information about memory problems, and dementia. Build this requirement into contracts, making use of a range of media and ensuring that that information meets people’s changing needs. |
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