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White Rose Surgery

Primarily a GP surgery. Open 7-7 Monday to Friday and 8-12 Saturdays. We operate over a 3 site structure and also provide many secondary care facilities such as theatres, endoscopy, Dexa scan, audiology, gym, xray and ultrasound. We pride ourselves on our ability to offer same day appointments and telephone advice. We have a large elderly population as well as being situated within a socially deprived area with high unemployment and high levels of obesity and smoking related diseases.

17 February 2015
Yorkshire and Humber
Health, Medical
Local Alliances:
Wakefield and Five Towns Dementia Action Alliance, Yorkshire & Humber Dementia Action Alliance

1. Action Plan

1. The National Dementia Declaration lists seven outcomes that the DAA are seeking to achieve for people with dementia and their carers. How would you describe your organisation’s role in delivering better outcomes for people with dementia and their carers?

Through improved diagnosis rates (including earlier diagnosis).

Through support to carers.

Through promoting awareness of what we are doing.

We work we local organisations such as Age UK and the community services to jointly care for isolated individuals with memory problems. Our award winning surgery prides ourselves on providing a patient centred care delivery ethos, and works well with surrounding organisations, carers and services. We have several care homes within our area and we maintain excellent working relationships with the staff within these homes, and offer daily advice to their staff.

2. What are the challenges to delivering these outcomes from the perspective of your organisation?

An increased number of patients on the practice’s register.

Identifying resources.

Communication and IT difficulties are a main concern and obstacle to true joined up care for patients. Differing IT systems within primary, secondary and other organisations is a major inhibitor to providing effective care. Delivering effective care is heavily dependent on the resources available. Better joined up care between organisations can overcome this somewhat. Effective diagnosis and treatment for dementia also relies on outside services e.g. mental health teams, memory service, community nurses. All of these are outside of the GP surgery.

2. Actions

  • Improving rates of diagnosis/ earlier diagnosis

    Working in partnership with Age UK we are offering preliminary screening to those of our patients who are in the following categories

    • Flagged on their patient records as having memory difficulties
    • Have had a number of admissions to Accident and Emergency in the preceding 12 month period
    • Have conditions which can predispose an individual to developing dementia (identified on the “At Risk of Dementia” register
    • Work in partnership with Age UK to offer screening and assessments to high risk patients e.g. over 50 with long term conditions, especially elderly housebound patients.

    Identify on the patient’s records who is most at risk, already having memory problems but no diagnosis, multiple a&e attendances, high risk long term conditions etc. write to patients to inform them of the process and the option to “opt out”. arrange for age uk to visit and assess the patient using a recognised memory assessment tool.

    Delivery, Implementation, Initial Scoping
  • Support after diagnosis

    White Rose Surgery was the first GP locality to introduce the concept of a virtual ward for people with dementia, housebound and other long term conditions.

    The Virtual Ward provides a structure to link a range of relevant services, including: physiotherapists; occupational therapists; matrons; Age UK and other voluntary sector organisations. Although the virtual ward is no longer funded by the CCG, we still strive to operate a joined up collaborative style of working. 

    Identify key stakeholders in the care of patients with dementia and strive towards a more collaborative way of working. We aim to arrange a joint meeting with the community teams and patient advocacy groups.

    Implementation, Initial Scoping
  • Supporting carers

    The White Rose Surgery has linked into The Carers Project - funded by the Department of Health. This is a network of community nurses who are committed to supporting the needs of carers.

  • Staff education

    Educate staff working within the practice who are not clinicians on the signs, symptoms and effects of dementia and memory problems, and how to liaise with patients who may be having difficulties with this to aid earlier diagnosis.

    Arrange training and discussion sessions for admin and reception staff on ther above points - what to do, how the diagnosis is made, what is available in the community/ treatment.