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GMS Contract Guide - Dementia

Dementia is worth 20 points, generating £2,492 for the practice with average list size and prevalence in 2007/8.

Dementia: Clinical Indicators
Target (%)Points
Register of patients with dementiaRegister5
Ongoing management
Patients whose care has been reviewed in the past 15 months6015
Total 20



  • The prevalence of dementia increases significantly from approximately one in 20 over age 65 to one in five over age 80. Approximately three-quarters of a million people are estimated to suffer from dementia in the UK. Alzheimer’s disease accounts for 50–75 per cent of cases of dementia.

  • National prevalence rates for England and Northern Ireland for dementia in 2006/7 were 0.4 per cent in England and 0.52 per cent in Northern Ireland. Figures were not yet available for Scotland and Wales as we went to press.

  • There are two indicators in this disease area. The first requires practices to establish a register of patients diagnosed with dementia, largely of diagnoses made in secondary care but including GP diagnoses where a referral to secondary care is inappropriate. The second indicator requires practices to conduct an annual face-to-face review of patients on the register, covering mental and physical health needs and the support needs of patients and carers.

  • Dementia is one of three indicator sets in the QoF covering aspects of mental health. The original mental health disease area covers serious mental illness, such as schizophrenia, and an indicator set for depression was also introduced in 2006/7.

  • There may be some crossover between the dementia register and the indicator set for palliative care.

Step 1: Setting up the register

  • The register is worth five points and should consist of all patients with a recorded diagnosis of dementia.

  • If you are confident you have accurate and complete electronic records, this can be accomplished by a search on Read codes used by the practice. Alternatively or additionally, you may need to carry out searches based on relevant medications and/or inspect notes manually. A key source of information, if they have not been correctly coded already, will be hospital letters. The guidance suggests that diagnosis will largely be recorded from correspondence from secondary care. If you are not already doing so, set up a system to make sure the preferred Read codes are used in future, including diagnoses from secondary care.

  • Diagnoses in primary care should be included in the indicator set; check if anybody is missing by circulating the initial list of patients to the primary care team.

  • Perform a rough prevalence check against national rates, taking into account your patient profile.

Step 2: Carrying out the annual reviews

  • The second indicator, worth 15 points, is to carry out an annual review of patients on the dementia register. This should focus on the support needs of patients and carers.

  • Note that the guidance specifies that the review needs to be carried out face-to-face. You need to decide who will carry out reviews and whether they need any training, and set up a call and recall system for patients on the register.

  • The review is expected to cover four key areas:
    - Review of patient's physical and mental health.
    - If applicable, carer's need for information related to the stage of illness and carer's and patient's health and social care needs.
    - If applicable, the impact of caring on carer.
    - Communication and co-ordination with secondary care, again if applicable.

Step 3: September to March

  • Run regular searches to find out which patients on the dementia register have not yet attended for their annual review and issue fresh invitations to those who have not yet been reviewed.

Useful Resources for Dementia

1. Audit Commission Report Forget Me Not 2002
2. National Service Framework for Older People

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