Diagnosis and Post-Diagnostic Support in Primary Care

The Post-diagnostic Support (PDS) in Primary Care programme was commissioned by Scottish Government to test the relocation, or closer alignment, of dementia diagnosis and PDS into primary care.

In March 2018 Focus on Dementia began working with three GP clusters – Shetland, East Edinburgh and Nithsdale in Dumfries and Galloway. Each selected site was supported to innovate in order to allow for a greater range of learning from aspects of delivery that best suited local contexts. This resulted in the following changes:

  • Nithsdale testing nurse and occupational therapist-led dementia diagnosis and locating this in clinic in GP surgeries
  • East Edinburgh delivering pre- and post-diagnostic support and PDS group-work from their surgeries, and
  • Shetland’s nurse-led diagnosis assessment service being completed by a discrete PDS practitioner.

You can watch the animation below which summarises the key activities.

Blake Stevenson Ltd, an independent social research company, externally evaluated the work to fully capture and report on the impact of relocating dementia expertise into primary care. 

The evaluation of the primary care dementia innovation sites report provides a summary of learning and outcomes from the programme and provides an overview of the:

  • quality improvement methods used to support the programme
  • engagement with stakeholders during the programme
  • outputs produced to support the programme, and
  • key learning from our programme evaluation.

Healthcare Improvement Scotland also produced an overview report outlining the key findings and our role in the programme. 


Virtual groupwork case study 

East Edinburgh Post-Diagnostic Support in Primary Care site introduced virtual groupwork sessions for people with dementia and their carers when, due to the COVID-19 pandemic, the team could no longer host face-to-face sessions. They produced a case study to share their experience.

Read the East Edinburgh virtual groupwork sessions for people with dementia and their carers case study


Videos from staff involved  

To hear the experiences of different staff members from across this programme of work, you can list to our in conversation with videos which give you the perspective of those involved in testing diagnosis and post-diagnostic support in a primary care setting.  

Connecting Dementia Support to East Edinburgh GP Cluster – Becki Ballard, Project Manager
Connecting Dementia Support to East Edinburgh GP Cluster – Joan Hogg, Dementia Support Facilitator
Connecting Dementia Support to East Edinburgh GP Cluster – Dr Andrew Mackay, Cluster Quality Lead
Basing Dementia Diagnosis Clinics in Primary Care in Nithsdale – Jacqui Pike, Occupational Therapy Service Manager (Mental Health)
Completing the pathway from diagnosis to post-diagnostic support in Shetland – Alan Murdoch and Nikola Hogg, Dementia Assessment Service

A guide to making general practice dementia friendly

People with dementia can experience difficulties in attending general practice, which can create barriers when even the best care and support is in place. They may experience difficulties with:

  • not remembering to attend appointments
  • navigating the physical environment of the practice
  • not being able to express their concerns in the short time available with the GP and
  • not recalling details of discussions regarding their care.

Experiencing difficulties when accessing GPs can impact on the quality of life and the health of people with dementia and their carers. It can also impact on the usage of primary care, emergency admissions to hospitals and transitions to residential care. 

We have created a guide to making general practice dementia friendly alongside Alzheimer Scotland which is a self-assessment tool to enable GP practices to become dementia friendly. 

Read a guide to making general practice dementia friendly


Using 'a guide to making general practice dementia friendly' case study

Benbecula Medical Practice were interested in using the guide and checklist to facilitate a structured approach to improving the way they work to support the patients in their practice who live with dementia. In this case study, Benbecula Medical Practice share their experience of using the guide.

Read the Benbecula Medical Practice using a guide to making general practice dementia friendly case study


How can I get involved? 

To ensure everyone can benefit regardless of their characteristics or where they access care, we completed an equality impact assessment. This highlights key equality issues that were considered by our project team, and any actions we took in relation to them. We are keeping this EQIA under review as the project progresses and we may update it if we receive new information.

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