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Dementia Programme supports the delivery of the core clinical programmes within the Long Term Plan and the Mental Health Implementation Plan 2019/20 - 2023/24 (the Implementation Plan) by connecting commissioners, providers, professionals, patients and the public across pathways of care with the aim of improving health outcomes. This is achieved by sharing best practice and innovation, assessing and benchmarking quality and outcomes and driving improvement where required, through targeted support.


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Laura Ansboro

Clinical Network Manager

Heather Stonebank

Quality Improvement Manager

Dr Sara Humphrey

Dementia and Older People’s Mental Health Clinical Lead

We align with the Adult Mental Health Clinical Network programme on topics including all-age models, NHS Talking Therapies and Community Mental Health Transformation and with aspects of the Palliative and End of Life Care Clinical Network work programme. We also work closely with colleagues within the NHSE Regional Mental Health and Ageing Well Delivery Teams, OHID (Office for Health Improvement and Disparities) and Yorkshire and Humber Improvement Academy.

What We Are Trying To Achieve

The NHS England Well Pathway for Dementia provides a framework for improving care for people affected by dementia. This framework sets out what good quality care means at each stage of the Well Pathway - Preventing Well, Diagnosing Well, Supporting Well, Living Well and Dying Well and includes statements showing what a good experience of care should be like for the person.

The Prime Minister’s Challenge on Dementia set out the ambition that at least two-thirds (66.7%) of people living with dementia should have received a diagnosis. In most cases, this diagnosis is given following referral to a specialist service, called a Memory Service or Memory Assessment Service (MAS).

Receiving a diagnosis of dementia should provide the gateway to accessing good quality care and support – both for the person living with dementia and for those who care for them. This support should be delivered in a way that is tailored to the needs of the person and their family and be available right through to the end of their life.

By focusing on quality improvement and working collaboratively with Integrated Care System colleagues and staff working across health, social care and voluntary sector services the Network supports the delivery of the Well Pathway for Dementia and improved care for people who are affected by dementia.

Key Aims
  • Maintain the dementia diagnosis rate of two thirds (66.7%) of estimated prevalence
  • Improve pre and post-diagnostic support for people affected by dementia
Key Deliverables

Support appropriate steps being taken to support post-pandemic recovery of the Dementia Diagnosis Rate (DDR) by supporting systems to:

  • Ensure capacity in Memory Assessment Services (MAS) is maintained and prioritised wherever possible
  • Work closely with primary care to ensure appropriate referrals to memory services
  • Develop close partnership with local care homes to ensure people in residential settings have equitable access to diagnosis

Support the delivery of high quality, person-centred care before, during and after diagnosis and including carer support.


Why It’s Important

The COVID-19 pandemic has had a disproportionate impact on people who are affected by dementia. Nearly half of the respondents to an Alzheimer’s Society survey said that their mental health had got worse during the pandemic (Worst Hit report).

An Age UK report also indicates that the social restrictions associated with the pandemic have accelerated cognitive decline among older people.

During the pandemic, there has been a significant reduction in the number of people being diagnosed with dementia and the support available to those people living with dementia and their families. For many people with dementia and carers, the sudden loss of formal support services had a negative impact on their quality of life (Impact of COVID report).

The latest data for dementia diagnosis, referral rates to memory assessment services, medication reviews and antipsychotic prescribing can be found on the NHS Digital Recorded Dementia Diagnoses webpage and the NHS Digital dementia publication.

For dementia care plan reviews, the latest reporting can be found in the Quality and Outcomes Framework data publication 2020-21.

What We Have Achieved In The Last 6 Months:

  • Provided clinical support to the national Dementia and OPMH team to update and refresh the Yorkshire and Humber Dementia Quality Toolkit and primary care templates, with a view to these becoming national resources.
  • Delivered dementia-focused webinars including Purple List – A Gay Dementia Venture and during dementia action week, ran 2 webinars focused on raising awareness of dementia diagnosis.
  • Liaison with other Clinical Networks, Commissioners and Providers across the country to learn from good practice models and intervention.
  • Contributed to development and phase 2 delivery of national memory services evaluation




What We Plan To Do In The Next 6 Months:

  • Support development of joint system plans in all ICS areas, to ensure appropriate memory service provision and collaborative working between memory services, primary care, and care homes.
  • Continue to support development and delivery of phase 3 of national memory services evaluation, including identification and sharing of good practice from across the country.
  • Update and publicise key resources to support recovery of the Dementia Diagnosis Rate.
  • Development of new toolkit to support review and appropriate deprescribing of Antipsychotics – in conjunction with national team and colleagues from London Clinical Network
  • Develop a data pack collating the key national data relating to dementia and older peoples mental health.