The Evelyn Medical Centre

We are a rural GP practice in the lovely countryside of the Hope Valley, Peak District and care for a population of approximately 6000 patients. Most of our staff live in the area and as such know our patients well. We strive to offer an excellent service to all especially in times of crisis.

3 March 2017
East Midlands
Local Alliances:
Derbyshire 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?

We as an organisation aim to provide the highest standard of care for our dementia patients in order to provide optimum outcomes in line with the National Dementia Declaration.

 We undertake opportunistic screening for dementia as well as responding to patient or career concerns. Providing a timely diagnosis is very important to help people to live well with dementia, and this is achieved by firstly assessing their memory capabilities and assessing their holistic needs. A referral to specialised services is required for diagnosis after appropriate investigations and once a diagnosis has been obtained a care plan is put in place taking into account the personal choices of patient and carers; the support services available, and their role in the community. We try to allow the patient to have control and influence in the decision making and provide whatever support is needed e.g. medical, befriending services, and dementia support groups. We also support patient and their carers on a long term basis.

Information and advice is available for people when needed so that everyone feels supported and able to ask for advice.

Our doctors and support team are trained in dementia awareness and our aim is to ensure our patients with dementia are living well in spite of their diagnosis.   

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

We are a very busy practice of 5950 patients so we are spread thinly on the ground covering a wide range of medical and management issues, particularly having a relatively high proportion of elderly patients.

Lack of resources.

Relative lack of the resources available to offer to patients when diagnosed and throughout to support them with any concerns or questions they may have.

Staff turnover – training new staff as part of induction.

We have quite an elderly population in our practice area and a 1% prevalence of dementia. This is below the national average but we feel that there are probably a significant number of patients with undiagnosed dementia or who have refused referral so we have to remain vigilant and use every opportunity to maximise the possibility of case-finding.

2. Actions

  • To improve the level of support to patients and carers post-diagnosis to ensure they are living well with their diagnosis.

    Alert boxes on screen to alert staff to patient with dementia diagnosis to allow extra time if needed for meeting their administrative needs such as making appointments etc. This would allow staff to allocate patients extra appointment time as appropriate.

    Invite each dementia patient in to surgery for a 30 minute consultation with our Dementia Champion reviewing current health and medication and working through bespoke template. A care plan will be offered as part of a dementia pack for each patient including additional leaflets/booklets. This would be reviewed on an annual basis.

    Work on increasing information re carers and obtaining permission to speak to relative as required.

    We also have a MDT meeting once a week which is attended by clinicians and Dementia Champion and any concerns regarding specific patients can be brought up in a safe confidential environment.


    2017 - First Quarter Update

    New Member

  • Maintain and if possible improve our service for those with dementia by ongoing staff education and review of service provision.

    We currently have meetings each month with all staff and any concerns can be raised by any staff regarding dementia support in the surgery. 

    We have a designated Dementia Champion to oversee dementia care, support and promotion and also to educate staff.  This will include new staff to the practice and will be worked into the new staff induction process.

    Ongoing training via Dementia Champion

    Online training through Blue Stream Academy

    We will have regular walk-throughs at the surgery to ensure that our environment is dementia friendly and that we are keeping on top of any changes occurring. 



    2017 - First Quarter Update

    New Member