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Undertaking the dementia enhanced service in 2015/16

A summary of what is involved in the facilitating timely diagnosis and support for people with dementia ES for England.

Two new groups of patients are included in the at-risk category for the 2015/16 ES (Picture: iStock)
Two new groups of patients are included in the at-risk category for the 2015/16 ES (Picture: iStock)

Key changes from 2014/15

  • The ‘at risk’ group has expanded to include patients over-60 with a ‘high risk’ of CVD and patients over 60 with COPD (see 'service specification' below).
  • Funding for this ES remains the same as in 2014/15 (see 'payment' below).


The aims of the ES in 2015/16 are to encourage GP practices to:

  • Identify patient at clinical risk of dementia
  • Offer an assessment to detect possible signs of dementia in those at risk
  • Offer a referral for diagnosis where dementia is suspected and referral is considered appropriate
  • Increase the health and wellbeing support offered to carers of patients diagnosed with dementia.


From 1 April 2015 for one year.

Practices must decide whether to participate within 42 days of being offered the ES by their commissioner.


Payment will be made in two components, with each allocated approximately half of the total funding for this ES. Funding remains the same as in 2014/15.

  • Component 1: An upfront payment of 37p per registered patient (this represents £2,622.19 to the average practice with a list of 7,807). Payment will be made by commissioners to practices no later than 31 July 2015.
  • Component 2: end of year payment based on the number of completed assessments carried out by the GP practice during the financial year as a proportion of the total number of assessments carried out nationally under this ES.*

*If a practice has completed 38 assessments for dementia during 2015/16 and the national total is 250,000 the practice gets a £3,192 component 2 payment (38/250,000 x total funding £21 million = £3,192).

Practices are required to manually input data into CQRS on a quartlerly basis under GPES becomes available to conduct electronic data collections.

Service specification

  • Opportunistically offer assessment for dementia to at risk patients on the practice’s registered list.
  • For the purposes of the ES ‘at risk' patients are:
    • aged over 60 with CVD, stroke, peripheral vascular disease or diabetes;
    • aged over 60 with a ‘high-risk’ of CVD, eg because of smoking, alcohol consumption or obesity (new for 2015/16);
    • aged over 60 with COPD (mew for 2015/16);
    • aged over 40 with Down’s syndrome;
    • other patients aged 50 plus with learning disabilities;
    • those with a long-term, neurological condition with a known neuro-degenerative element;
    • any patients who raise a memory concern.
  • The assessment must only be undertaken following establishment of patient consent.
  • The assessment offered to consenting at-risk patients should be undertaken following initial questioning to establish whether there are any concerns about the patient’s memory.
  • Where there is a concern about memory the assessment should involve conducting a more specific tests to detect any signs of dementia, such as GPCOG or another validated tool.
  • Analysis of the assessment results should be carried out by a healthcare professional with knowledge of the patient’s current medical history and social circumstances.
  • If dementia is suspected the practice should offer a referral where appropriate to specialist services, respond to any other identified needs arising from the assessment and provide any treatment that related to the symptoms of memory loss.
  • Patients diagnosed as having dementia should be offered an advanced care planning discussion focussing on their physical, mental health and social needs – including referral/signposting to local support services.
  • The care plan should:
    • detail the patients wishes for the future
    • identify the carer and give permissions for the practice to speak directly to the nominated carer
    • provide details of the support services available.
  • The practice should ensure any carer registered with them is offered a health check to include signposting relevant support services.

Read codes to use

  Read v2
Read CTV3

To assist in identifying any patient in an at risk group

At risk of dementia
14Od. XaQyJ

To record initial questioning for memory concern (or offer)

Initial memory assessment
DemTect scale
38Qj. XabVK
Everyday cognition questionnaire 38Qv. Xabp1
Mini-mental state examination 388m. XM0fo
Six item cognitive impairment test
GPCOG – general practitioner assessment of cognition 38Dv.
Initial memory assessment – declined

To record an assessment (or offer) for dementia in patients with a memory concern

Assessment for dementia
38C10 XaaBD
Dementia screening declined
8IEu. XaaTn
Dementia screening questionnaire declined

To record any referral (or offer) for a diagnosis of dementia

Referral to memory clinic
8HTY. XaJua
Referral to memory clinic declined
8IEn. Xaa9t
To record advance care planning
Dementia advance care plan agreed
8CSA. XabEk
Review of dementia advance care plan
Dementia advance care plan declined
8IAe0 XabEi

To record, for diagnosed patients, any identified carer and offer of a health check where the carer is registered with the practice

 Carer of person with dementia  918y.
 Carer annual health check  69DC.
 Carer annual health check declined
 No longer carer of patient with dementia  918f0  XaboS

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