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Airedale, Wharfedale and Craven Clinical Commissioning Group

Membership of the CCG is made up of 16 GP practices working together to plan and commission local health services for a population of 156,000. We cover two local authority areas and aim to be a leading CCG through successful integration and transformation of health and social care, the introduction of innovative, improved clinical pathways, sound financial management and a model employer, developing future clinical leaders. Our CCG has been identified as a national integrated care pioneer site. It is developing new models of care so people in the CCG’s area receive individual seamless care, reducing their need for urgent and unplanned care by proactively managing their physical, psychological and social care needs. The CCG new models of care programme is looking at new ways of working in different areas of health and social care, including the four projects below: • complex care • enhanced care • wrap around care • self -care Airedale, Wharfedale and Craven is one of 25 of the national Pioneer sites acting as an exemplars to address local barriers to delivering integrated care and support locally, and highlight national barriers that national partners can work to address. We are supporting the rapid dissemination, promotion and uptake of lessons across the country and receive support to breaking down these barriers from the national partners.

23 January 2017
Yorkshire and Humber
Clinical Commissioning Group
Local Alliances:
Bradford District Dementia Action Alliance, Settle Dementia Action Alliance, Yorkshire & Humber Dementia Action Alliance, Skipton & South Craven 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?


Our vision for health and social care in Airedale, Wharfedale and Craven is that;

Our population will be healthier, happier, more independent and have access to high quality care that is clinically and financially sustainable.

 People in Airedale, Wharfedale and Craven will be supported to stay healthy, well and independent through a focus on healthy lifestyle choices and self-care.

 When people need access to care and support it will be available to them through a proactive and joined up health, social care and wellbeing service. The care will be tailored to people’s individual needs, irrespective of their condition, age or where they live and will be available 24 hours a day, 7 days a week, 365 days a year.

 Our role in supporting delivery of better outcomes for people with dementia and their carers is through our commissioning for outcomes arrangements ensuring parity of esteem and that physical, psychological and social needs are taken into account when assessing need to ensure delivery of high quality care. Our aim is that at all times our population receives care and treatment that is of the highest quality ensuring it is safe, effective, person- centred, efficient, timely and equitable. Our ambition is to work with our stakeholders and providers to continually improve services. This will ensure that services are delivered in the right place, at the right time, by the right staff.  

 We commission pro-active models of care, including a range of community based services, supporting care at home, avoiding unnecessary hospital admissions. We work closely with partners to improve access to care and explore and develop new solutions in managing dementia and supporting people with dementia and their carers.

 As commissioners we work closely with our providers in the planning, delivery and monitoring of services they provide. We do this by developing close working relationships across a number of organisation’s from the health, social and voluntary sectors.

 In order to understand how our services are doing and inform improvements, we benefit from feedback from both patients and carers, welcoming communications that allows us to celebrate the positives and to challenge, to learn and to change when an experience or expectation has not been met.

 We aim to ensure all newly commissioned services are developed with a dementia friendly approach taking a holistic view of the person to provide patient friendly, person-centred care and support

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

Our main challenge is the unprecedented, prolonged financial challenge to the health and social care sector, twinned with rapidly rising demand. We are developing and implementing a delivery system of health and utilization to operate in a way, better suited to the 21st century health needs of our population.  The CCG covers an area where 23% of population are aged 65+ and 30% forecast to be 65+ by 2021

In order to achieve this our aim is to :

  • Change the mind-set of professionals to promote active participation in health and wellbeing of the individual
  • Change the mind-set of the public so they become an active participant in their health and care

Commission and support  health services that support people to take responsibility for their health and wellbeing

2. Actions

  • Preventing well: Minimising the development of dementia through promotion of healthier lifestyles

    AWCCCG has a significant role to play in partnership with local authorities and other partners to work on dementia risk reduction.  By promoting the Public Health England campaign on health inequalities and dementia that aims to educate and change the mind-set of the public we will encourage people to move away from thinking that dementia is simply an inevitable part of ageing as studies suggest that up to a third of dementia cases may be attributable to potentially modifiable lifestyle risk factors.

    We will support health providers to implement NICE guidelines making recommendations on approaches in mid-life to delay or prevent the onset of dementia, disability and frailty in later life.

     We will encourage adults 40-74 to take up GP based NHS Health Checks, providing them with the opportunity to manage their health better.

    We are funding and facilitating motivational training for health care staff across the patch to support patient activation to encourage people in being a partner in their own care, enabling them to self -manage in the community.

    Use of PHE’s dementia profile tool and health intelligence to inform the provision of care of people who have dementia, identifying local risk factors for dementia such as smoking prevalence, physical activity, excess weight and alcohol related hospital admissions


    2016 - Second Quarter Update

    New Member

  • Diagnosing well: Sustain and improve dementia rates across the CCG

    Developing an access and waiting time for dementia so people with dementia have equal access to diagnosis as for other conditions.  Setting the national average for an initial assessment at six weeks in the memory assessment services we commission.

    We have achieved above the national average for diagnosis rates across the CCG so we will continue to monitor progress to ensure that the ambition is maintained and we will address any variation in diagnosis rate at the CCG level and address any reduction that might occur in current achievements.

    Monitor diagnosis rates against national targets and sustain and improve above national average dementia rates across the CCG area

    Continue to encourage general practices to make an early diagnosis and referral of people with suspected dementia

    Delivery, Implementation

    2016 - Second Quarter Update

    New Member

  • Living well: People with dementia and their carers are supported to live well and feel included as part of society

    AWCCCG has jointly commissioned with 2 other CCG’s and 2 local authority Carers Resource to provide support to people with dementia and their carers

    AWCCCG has registered with Dementia Friends and organised information sessions to help members of our organisation understand dementia and how it may affect a person as well as registering as individual dementia friends. We continue to support local dementia friendly events.

    Working collaboratively with a local authority, 2 other CCG’s and public health to review  and improve the post diagnosis care and support pathway with a view to re-design in line with NHS England’s focus on improving post diagnostic support.

     Implementing STAR a multi-criteria decision analysis (MCDA) procedure for people faced with a set of options to systematically rank their preferences using a range of different criteria. By combining a technical value-for-money analysis with extensive stakeholder engagement and discussion, Star enables local commissioners to involve the wider community in the evaluation of a range of current or potential healthcare interventions.

    Delivery, Implementation

    2016 - Second Quarter Update

    New Member

  • Dying Well: People living with dementia die with dignity in the place of their choosing

    We commission community services that provide community ’Hospice at Home’ end of life care at home bringing the skills, ethos and practical care associated with the Hospice movement to enable patients with advanced illness to be cared for at home, and to die at home if that is their preference.

    We also commission and support The Gold Line, a dedicated service for people who are being cared for on the Gold Standards Framework offering a gold standard of care for people with a serious illness who may be in their last year of life so that every patient can receive the right care, in the right place, at the right time.

    One acute provider is delivering SAGE & THYME training to staff supporting end of life patients to increase staff confidence around difficult conversations with a person in distress or with concerns.

    Delivery, Implementation

    2016 - Second Quarter Update

    New Member

  • Supporting Well: Access to safe high quality health and social care for people with dementia and their carers

    We continue to commission our acute providers to provide telemedicine and telehealth into local care homes and to deliver training for staff in dementia care. 


    We support  improved GP relationships with care homes increasing the provision of quality care and reducing inappropriate admissions into hospitals


    We are working closely to support Airedale and Partners Enhanced Health Vanguard as part of the NHS England ‘Health as a Social Movement’ programme. Working with a number of care homes across the Airedale area in West and North Yorkshire and key external partners locally and nationally in a ground-breaking new project aimed at improving the lived experience for people with dementia by putting care homes at the centre of their local communities

    We support the adoption of the National Butterfly scheme by acute providers to deliver a system of hospital care for people living with dementia or who simply find that their memory isn’t as reliable as it used to be.


    2016 - Second Quarter Update

    New Member