Working with health and social care partnerships to improve post-diagnostic support, care co-ordination in the community and hospital care for people living with dementia and carers

Healthcare Improvement Scotland has been delivering dementia improvement programmes since 2016, working collaboratively with health and social care dementia services to:

• Support teams, as part of the Dementia in Hospitals Programme, in acute, community and specialist dementia unit settings to improve person centred- care planning and the prevention and management of stress and distress. For more information visit the Dementia in Hospitals Programme webpage.
• Support the testing of connecting dementia diagnosis and post-diagnostic support into primary care with three GP Clusters as part of the Diagnosis and Post-Diagnostic Support in Primary Care Programme. Improved accessibility and uptake in one site rose from 42% to 84%. In another, wait times for dementia diagnosis was reduced from 9 months to 6 weeks. For more information on the three GP Cluster sites and the programme visit the Diagnosis and Post-Diagnostic Support in Primary Care webpage.
• Improve the quality of post-diagnostic support (PDS) for people newly diagnosed with dementia by creating a PDS Quality Improvement Framework and facilitating a forum for PDS Leads across Scotland to share practice and link with national partners to support and inform dementia strategy implementation.
• Support improvements and redesign of Inverclyde dementia services through collaborative working with Inverclyde Health and Social Care Partnership. For more information visit the Inverclyde Care Co-ordination webpage.
• Commission an inquiry, in partnership with Alzheimer Scotland, to explore and understand Midlothian Health and Social Care Partnership's approach to care co-ordination in the community for people with dementia and their carers. This work identified twelve critical success factors to delivering successful co-ordinated care to people with dementia. For more information read the Care co-ordination in the community for people with dementia in Midlothian: summary of an appreciative inquiry and data analysis to understand the critical success factors.
• Support Specialist Dementia Unit demonstrator sites to reduce falls by 54%, staff sickness by 74% and stress and distress by 33% leading to a reduction in medication. For more information read the Specialist Dementia Unit Improvement Programme summary report.

Current dementia programmes

Focus on Dementia Improvement Programme

The programme has three elements:

• Post-diagnostic Support Improvement Support - working with teams to make improvements to PDS services accessed by people living with dementia and their carers.
• Dementia in Hospitals – testing the resource ‘Improving Observations Practice’ (IOP) for people with dementia in hospital using a person-centred approach.
• National Focus on Dementia Learning System - sharing the learning from all of our current and previous community and hospital programmes and ongoing facilitation of PDS Lead and dementia practitioner networks.

The programme  includes a focus on meeting guidelines and aspirations in the new Dementia SIGN Guideline (due to be published Autumn 2023), the local delivery plan standard for dementia, the standards of care for dementia, and the fourth national dementia strategy (published 31 March 2023). 

The programme runs from July 2023 to June 2024. To find out more contact the team at his.focusondementia@nhs.scot​

Previous dementia programmes

You can find out more and continue to access the resources from our previous programmes:

• Dementia in Hospitals: worked with teams in acute, community and specialist dementia unit settings to improve person centred- care planning. This person-centred approach aimed to support the prevention and management of stress and distress. A final report with case studies and change package are being developed and will be published in due course. 
• Diagnosis and Post-Diagnostic Support in Primary Care: worked with three GP Clusters, Shetland, East Edinburgh and Nithsdale in Dumfries and Galloway. The programme supported the testing of the relocation, or closer alignment, of dementia diagnosis and PDS into primary care. Key outputs from this work include a guide to making general practice dementia friendly and a case study. An external evaluation report was produced by Blake Stevenson Ltd, Evaluation of the primary care dementia innovation sites report as well as an internally produced report, Post-diagnostic Support in primary care for people living with dementia overview report.
• Diagnosis and Post-Diagnostic Support: worked with PDS Leads to improve the quality of PDS for people newly diagnosed with dementia in Scotland. The programme supported the development and facilitation of a forum for PDS Leads across Scotland to share practice and link with national partners in order to support and inform dementia strategy implementation. Key outputs from this work include the Quality Improvement Framework for dementia post-diagnostic support in Scotland, the adoption of the post-diagnostic support single quality question and the PDS Leads Network.
• Inverclyde Care Co-ordination Programme: worked with Inverclyde Health and Social Care Partnership to support improvements and redesign of community based services to improve the experience, safety and co-ordination of care for people with dementia from diagnosis to end of life care. The programme supported people to stay well at home or in a homely setting for as long as possible. Key outputs from this work include a palliative care identification tools guide for staff supporting people living with dementia, the Inverclyde dementia support and services leaflet, the care home guidance for people with learning disabilities who have dementia. An external evaluation report was produced by RSM Consulting LLP on behalf of the Scottish Government, Improving care co-ordination for people with dementia in Inverclyde report as well as an internally produced report, Care co-ordination in the community improvement programme overview report.
• Care co-ordination in the community for people with dementia in Midlothian: worked with Midlothian Health and Social Care Partnership to identify 12 critical success factors for integrated care co-ordination of people with dementia in the community. The key output from this work is the Summary of an appreciative inquiry and data analysis to understand the critical success factors.
• Specialist Dementia Unit Improvement Programme: worked with four demonstrator sites to improve quality of care for people with dementia within Specialist Dementia Units. The programme supported improvements in practice, participation and culture across the four units. Key outputs from this work include the online Dementia in Hospitals Improvement Toolkit, three case study films and the Specialist Dementia Unit Improvement Programme summary report.