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South-West Lincolnshire Clinical Commissioning Group

South-West Lincolnshire Clinical Commissioning Group is made up of 19 GP practices in Grantham, Sleaford and the surrounding villages. We care passionately about the NHS and the health needs of the local population. We are working together to improve the quality and delivery of health services for our patients and to help people live longer and healthier lives. High quality services should be easily available to everyone and the health professionals that work in our CCG are well placed to lead the development of local health services. Our CCG has its own budget to plan and buy the health services for people living in our area.

24 July 2017
East Midlands
Clinical Commissioning Group, Hospitals and Hospital Trusts, Local Authorities, Membership Organisations, Other
Local Alliances:
South West Lincolnshire 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?

The CCG is a substantial purchaser/ commissioner/ provider of a wide range of services which may be used by people with dementia, their families and/or their carers and a key stakeholder working with other partners who may also provide services to these patients. The services provided by its members, often front-line GP practices, may provide a first point of contact for patients worried about their memory or cognition and looking to engage with services.

As well as this, the CCG is an employer with responsibility for a range of clinical and non-clinical staff. Recent figures show that as many as 18% of people diagnosed with dementia, under the age of 65, continue to work for some period of time following  diagnosis and that 27% of carers of people with dementia also continue to work. This means that employers must consider how to address the needs of people with dementia and carers, in the workplace. The CCG acknowledges its responsibility to ensure it puts in place practical actions that will ensure it is a ‘dementia friendly organisation’ promoting the principles of a dementia friendly community in every way it can. 

The CCG is signed up to the Lincolnshire Joint Strategy for Dementia 2014-2017, which is committed to improving the experience of individuals and families receiving a diagnosis and living with dementia. We recognise the need to support individuals and carers as well as possible early on in order to help people live for as long as possible independently with family and friends at home. This strategy represents a commitment to make a shift in investment from acute care to preventative support. This strategy has been developed jointly by Lincolnshire County Council and NHS Clinical Commissioning Groups working closely with local partners, stakeholders, carers and people who use social care and NHS services.

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

The CCG faces a number of challenges in relation to the care and support it commissions - an increasing elderly population (75+); high demand for secondary care services; higher rate of emergency admissions and length of stay in some specialties compared to other areas; high levels of chronic illness; health inequalities across South-West Lincolnshire and the financial challenges faced by all of the NHS to do more with less.

Early diagnosis of, and intervention for, dementia are the keys to delaying admission to long term care and to helping people remain independent for longer. Making the diagnosis early means that there is the chance to prevent and plan for future problems and for people to benefit from positive interventions.

Promoting healthy ageing, for example keeping people active and tackling social isolation, is important in delaying the onset and progression of dementia.

Ability to meet increasing demand for the right services at the right time for people with dementia and their families throughout the dementia journey will continue to be a challenge which will require innovative practice and partnership working.

Involving people with dementia and their families in influencing personal choice and design of services and maintaining an active involvement in their community will also provide a challenge.

2. Actions

  • Dementia friendly organisations/environments

    We will work with partners to increase awareness of dementia and to increase the number of dementia-friendly organisations/environments in South-West Lincolnshire.


    2016 - First Quarter Update


  • Improve dementia diagnosis rate from 52.7% in March 2015 to 67% in March 2016.

    •  Review variation by practice and address unwarranted variation.

    •  Validating data. To ensure we have captured all people diagnosed we are revisiting data validation with all of our practices to check each practice has reviewed data with LMC, SUS, local mental health trust and will ask all practices if they are doing any additional data cleansing.

    •  Cross reference memory clinic assessment and diagnosis with QoF practice registers to ensure all patients are captured on the register.

    •  Ensure working diagnosis is given by memory clinics - discuss with Service provider (already notified and taken forward.

    •  Review of Memory Assessment and Management Service based in primary care in LWCCG to establish if this model can be effectively used in SWLCCG.

    •  Screening. Work on demand and capacity modelling (systems dynamic modelling) has shown that increasing diagnosis rates at the early stage of dementia will have the biggest impact on overall diagnostic rates in the CCG.  Therefore we have implemented CANTAB across the CCG to improve screening.

    •  Awareness raising campaign. Raise public awareness of importance of early diagnosis. Podcast (local GP and Alistair Burns) focused at GPs – benefits of early diagnosis and support and diagnosis in care homes.

    •  Arrange a workshop for local GP practices to discuss diagnosis and how to implement in practice.

    •  Work with SCN to undertake care homes audit across SWLCCG to support identification of people with dementia and add to QoF register.


    2016 - First Quarter Update


  • Education and awareness training.

    Increase awareness and education of South-West Lincolnshire CCG and Primary Medical Care Services staff of dementia.


    2016 - First Quarter Update


  • The CCG will develop an integrated care pathway for people at risk of or with signs of dementia.

    The CCG’s dementia pathway will be available to view on its Map of Medicine referral management system.

    We will work with our memory service provider to ensure that the service is accredited, to improve waiting times and to embed the pathway and processes.

    We will work with GP practices to continue to improve dementia diagnosis rates and to ensure they are fully aware of the local pathway around care and support for people with dementia.


    2016 - First Quarter Update