North London Partners in health and care

Dementia care in NCL - NHS evaluation

The Alzheimer’s Society report that over 40% of older people in hospital have dementia. Their length of stay will be twice that of people without the condition and a third of these patients do not even need to be there. People with dementia represent a quarter of delayed discharges and 10% of readmissions within 30 days [See Alzheimers Society, Fix dementia care: Hospitals].

In addition, of those who are admitted to hospital from their homes, over a half are then discharged into residential care. Hospitals are not a beneficial environment for people with dementia, evidence shows that the longer the stay the worse the effect on their dementia symptoms and physical health. They are also twice as likely to fall, an event which quadruples length of stay.

Three areas in England were identified as exemplars of best practice in dementia care: North Central London, West Yorkshire and Harrogate and Birmingham and Solihull with the aims to improve outcomes for people with dementia and their families by sharing examples of best practice and implementation details of identified initiatives. These initiatives can be implemented at borough, STP level and/or wider geographical footprints to help reduce unnecessary admissions to, and length of stay in, acute hospitals.

The North Central London examples are listed below, click a link for more information on each example.

North Central London STP was selected as an exemplar site due to the Dementia Awareness Programme; The STP has three of the best CCG dementia diagnosis rates in England in the latest 2019/20 report (Enfield, Camden and Islington at 88%, the national ambition is 67%). North Central London has the fastest dementia referral to diagnosis and access to post diagnostic support rate in London, with an average of 5.4 weeks against the NHS England & Improvement national ambition to increase the number of people being diagnosed and starting treatment to within 6 weeks of referral (2019/20).


Nationally it is estimated that 75% of care home residents have dementia, so a concerted effort and specific attention needs to support care homes to effectively provide dementia care.

The Care Home Assessment Team (CHAT) supports the wellbeing of patients in care homes. CHAT is a system wide partnership; an integrated multi-disciplinary mental and physical health team with strong links with primary care, specialist pathways such as frailty all underpinned by strong support from local Geriatricians and Consultant Psychiatrist.

By commissioning an enhanced integrated care homes service we have seen clinically significant improvements in patient outcomes and commissioning outcomes including a reduction in A&E attendances and non-elective admissions leading to substantial cost savings.

This service has reduced the need for acute emergency and reactive care, by improving the direct management of individual patients in care homes, improving the knowledge, skills and confidence of care home staff. And improve end of life care, increasing the number of residents who die in their preferred place.

 The Outcomes;

  1. There was 35% reduction (-2,118) in the total number of A&E attendances and non-elective admissions, compared to a 23% increase in Enfield’s 65+ year old non care home population. This equated to a 9% reduction in costs, against a 34% increase in costs for the general population aged 65+.Falls leading to hospital attendance or admission were reduced by 7% 
  2. 99% of residents died in their preferred place
  3. 39% of residents have had their medication reduced or stopped
  4. 8,409 hospital attendances and 8,109 GP call outs have been avoided
  5. 7,606 care home staff and managers attended training on 59 subjects

See the North Central London webpage for more information including full report, executive summary and toolkits for support in rolling out the model.

Camden and Islington NHS Foundation Trust’s Integrated Community Ageing Team (ICAT)

The Camden and Islington NHS Foundation Trust’s Care Home Liaison Service works closely with the Integrated Community Ageing Team (ICAT). They introduced clinical psychology-led support groups for care workers co-facilitated by a clinical psychologist and mental health nurse to increase knowledge about managing agitation, other neuropsychiatric symptoms and person centred care for care home residents with dementia, an increase in OT input and more support for care home Activities Coordinators. MDT meetings are chaired by the lead GP for the care home and attended by care home staff, the ICAT staff, a consultant geriatrician, a pharmacist, a specialist palliative care nurse, a speech and language therapist and a Liaison Service professional. This service has lead to;

For information on Crisis Resolution Home Treatment Teams and supporting older peoples mental health  go to webpage Dementia care in home treatment teams

Dementia Primary Care Network – Barnet Example

Care Closer to Home - Developing a new model of care and support for adults with dementia and their carers within Primary Care Networks. The new integrated multi-disciplinary teams will be aligned to Primary Care Networks to improve outcomes for patients with dementia specifically to improve care co-ordination and management of the illness closer to patient’s homes.

The PCN model will increase the dementia specific workforce; a Specialist Dementia Nurse in Primary Care, a Dementia CST and volunteer co-ordinator, a Adult Social Care Specialist Dementia Support Practitioner, a OP CMHT, including sourcing of estates utilising existing community spaces to deliver activities and host additional workforce. Integrated working with the local memory service, GP practices, VCS, social care, acute care teams and community care teams.

Benefits to be achieved include:

  1. Improved patient experience for adults with dementia and their carers: 
    Reduce variation in Dementia care
    Improve patient access to support, improved post diagnostic support, care co-ordination and clinical outcomes (preventing avoidable crises)
    An improved coherent approach to support being provided aligned to the integration agenda and the NHS Long Term Plan
  1. Better use of resources:
    Reduction in the number of appointments with GPs within primary care settings (NHSE reports the average cost of an appointment as £30 therefore, within PCN 5 based on an estimated reduction of 20% GP time allocated to supporting these patients a saving of £14,970 should be achieved)
    Reduction in the number of avoidable admissions for adults with dementia within secondary care settings (for PCN 5 estimated saving of £114,020 per annum- based on achieving a 20% reduction in emergency admissions)
    Additional longer-term savings may be achieved across the system through delaying / reducing demand for continuing health care funding and the need for high cost social care packages of care (e.g. delaying entry of patients into residential / nursing care settings by up to 20 months

 Please contact North Central London Partners in health and care  for more information including example business case and case for change, email 

The Enfield Memory Service Floating Consultant model is highlighted as one of the most effective models in London. In one clinic session 5-6 clients are booked in staggered appointments. They are initially assessed by memory service staff (nurses, OT, junior doctors). Each assessor in turn presents to the “floating consultant” who will then review the client with that member of staff. The consultant will deliver the diagnosis and a care plan initiated. If necessary they can perform more complex cognitive testing, physical examination and medical assessment. This is a cost effective use of consultant time and resources. It is popular with the team, who are supported with instant clinical supervision and the opportunity to upskill through real time peer learning.

NCL benefits from hosting the National Hospital for Neurology and Neurosurgery (NHNN), Queen Square, which is the UK's largest dedicated neurological and neurosurgical hospital. It provides comprehensive services for the diagnosis, treatment and care of all conditions that affect the brain, spinal cord, peripheral nervous system and muscles. Including support for patients and their carers with dementia. The Cognitive Disorders Service runs in parallel with the Dementia Research Centre (DRC), part of the Department of Neurodegenerative Disease at the UCL Institute of Neurology (ION). The clinical and research components form a national centre of excellence for diagnosis and treatment of patients with cognitive problems, and the group is recognised internationally for ground-breaking research in dementia.

  • Co-ordinate My Care (CMC) records are now used widely in NCL to make digital crisis plans for those in their last phase of life and those who are frequent users of urgent care services
  • There were over 7,600 Advanced Care Plans created on CMC in 12 months (October 2019 – October 2020)
  • The records are primarily created by GPs but are also completed and edited by community palliative care services
  • There has also been an increase in the records being viewed by 111 and LAS services in NCL
  • There is training and support for GPs both from CMC and from local community palliative care services and borough level GP clinical leads
  • The focus is now on ensuring that the CMCs created are effective in their use and are reviewed at least annually

The STrAtegies for RelaTives (START) is an eight week programme of individual psychological therapy sessions that supports the development of coping strategies for carers of people with dementia.

Caring for people can be challenging and stressful and about 40% of people caring for a family member with dementia have symptoms of depression or anxiety [1, 2]. The START intervention aims to reduce depression and anxiety in family carers. The programme is cost-effective and offers value for money for the health and social care system

See also