1. Memory assessment project - Surrey Downs CCG Joanna Gavins

2. Memory assessment project
Who was involved
Joanna Gavins, Project Manager, Dementia Challenge Project, Surrey Downs CCG
Dr Sen Kallumpuram, Consultant Psychiatrist and Clinical Lead, SABP NHS Trust
3 Dementia Link Practitioners

3. Project introduction Surrey Downs CCG awarded Dementia Challenge Funds
Improve low dementia diagnosis rates (43%)
Over 65s population 55,000
Screen, assess, diagnose, care plan
Support and final diagnosis by Consultant Psychiatrist
Specialist dementia link nurses (Band 6 OA MH)
Work with 33 GP practices
Identify early signs of cognitive impairment
Improve dementia knowledge in practices
Increase community awareness

4. Dementia link nurses care pathway

5. Diagnosis and care plan
Diagnostic process
Search GP Patient records
Over 65s ‘at risk’
Discuss with GP
Invitation for assessment
Screening
Mini cog and clock + functional activity tests
Further assessment by GP
Dementia blood screen
Referral to secondary care
Initial assessment
Comprehensive assessment
Provisional diagnosis
MRI or CT scan
Full diagnosis
Care plan
Diagnosis and care plan
206
2000
156
6000

6. Issues addressed Data sharing agreement Need for consultant
DNAs
Older cohort first
Wording of invite letters
Differing GP systems (4)
Defining search terms

7. Challenges To meet with Practice Managers in each GP surgery
To get buy-in from stakeholders i.e. GPs and patients
Willingness for change
De-stigmatise ‘Dementia’

8. Raising knowledge and awareness
4 GP awareness days
GPs, Practice Nurses, Support Staff
GP practices
4 Roadshows with Alzheimer’s Society
Radio
Schools
Public

9. Outcomes Improved diagnosis rates Knowledge and awareness
156 people directly diagnosed through the project
GPs and practice staff
Referral rates high - c.25 per week
Public
Surrey Downs diagnosis rates now 72%

10. The next step – Dementia Data Harmonisation
This project has helped pave the way for the Dementia Data Harmonisation work which involves improving data quality of Dementia diagnosis within primary care
There is still some work to be done to change the hearts and minds of GPs
There are still certain surgeries not willing to participate in the Data harmonisation work and so Clinical Leads are having to work harder in those area

11. Joanna Gavins Project Manager KSS Strategic Clinical Network
kssahsn.net