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CQC Essentials: Caring for people with dementia

GPs have a duty to recognise those at risk of dementia, provide timely diagnosis and refer appropriately to specialist services. When the CQC inspects GP practices it will look at how people experiencing poor mental health are cared for, including those with dementia.

This article relates to the CQC key question: Is your practice effective? Is your practice caring? and Is your practice responsive to people's needs? 

A recent thematic report Cracks in the Pathway reviewed the care provided to patients living with dementia when moving between hospitals and care homes. We found worrying variation in the quality of care received, and recognised that improvements need to extend far beyond institutional boundaries.

GPs have a duty to recognise those at risk of dementia, provide timely diagnosis and refer appropriately to specialist services. Evidence demonstrates that providing effective early interventions in dementia can:

  • reduce hospital admission rates
  • improve retention of cognitive function
  • increase quality of life reports for both patient and carers
  • save substantial funds for local commissioners and the NHS as a whole.

NHS England has published a useful guide to support GPs:

The recently introduced enhanced service for dementia rewards general practices for proactive diagnosis and management of patients living with dementia. It is designed to give patients more opportunity to plan their future, organise appropriate care and access treatment promptly.

The depth and breadth of this will vary for each practice depending on population demographics and list size. However, we expect that every practice should be able to demonstrate an awareness of their local population need and their efforts to address this.

NHS England has published detailed information:

Dementia care in general practice: the Gnosall model

Since June 2006 a specialist dementia service has been delivered by Gnosall Surgery that is making significant impacts on the diagnosis and care of patients living with dementia in the local area. By adopting an integrated model of care and delivering services under the wider registered activity of the local mental health trust, Gnosall Surgery has achieved staggering results:

  • Time to diagnosis reduced from three years to four weeks
  • 100% patient satisfaction
  • Less than 3% per annum patients with dementia admitted to institutional care
  • Excess bed days reduced by 25%
  • Zero usage of mental health services in-patient beds for assessment

The outstanding qualities of this care are:

Population groups:

Older people and people experiencing poor mental health have specific and dedicated models of care. The practice is able to demonstrate innovative practice with evident improvements in health and wellbeing.


Clinicians actively seek out patients who at risk of or are exhibiting symptoms of potential memory problems. The team is able to demonstrate remarkable improvements in patient outcomes, both from qualitative and quantitative data (see above and attached case reports), through regular monitoring processes.


The dementia clinic operating from Gnosall Surgery provides high quality holistic care, including access to advice and support regarding legal matters such as driving, and integrates well with local support groups. Case studies provided by the surgery demonstrate patients and carers being involved in care planning from the offset, with service users reporting a real sense of respect and patient-centred goal setting.


The practice demonstrates a comprehensive awareness of the needs of their local population. They have recognised a deficit in diagnosis rates for dementia, developing innovative methods to address this issue, and have strong leadership that has driven sustainable change. The practice team has published widely in academic and non-academic reports of their successes, lessons learned and opportunities for replication elsewhere, demonstrating exceptional vision, leadership, learning and improvement.

The practice model has been successfully replicated at several other sites and more are set to be implemented in 2015/16.

More details on Gnosall Memory Clinic:

Dr Emily Phipps who is a National Medical Director’s Clinical Fellow working at CQC

More CQC resources

Picture: iStock

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