Dementia Post Diagnosis Support

What was the issue you were addressing or working on?

Supporting people with a new diagnosis of dementia and their relatives/carers to be better informed about the condition, to understand the support available to them, and to plan for their future care.


What you did?

Delivery of the model involves triage by the Community Older People’s Mental Health Team, with allocation to a Link Worker either from Health or from Alzheimer Scotland. The Alzheimer Scotland Link Workers are funded from the Change Fund with NHS link workers identified from existing resources. The Link Worker liaises with the person with a diagnosis and their family, to develop a personal plan that ensures: knowledge about the condition; planning for the future including financial planning; access to peer support; and maintaining connections to the community as appropriate. Processes have been developed for referral to the Carer’s Centre (managed by Social Work), so that a carer’s assessment can be completed; and for referral to money advice services (run by Macmillan). We have also set up self-management groups to help people to manage their condition.


What were the outcomes - benefits or otherwise?

We have already evaluated our self-management group using questionnaires with clients and carers, and feedback was very positive.

We have now completed our first year of PDS in South Glasgow, and are completing an evaluation of this. We will have results available shortly from a survey of people supported by the service, and the staff involved. We anticipate that the benefits derived will be that people with a new diagnosis of dementia feel well-supported, and will know how to get support as symptoms develop. Longer term, the aim is to enable people with dementia to remain in their own homes or a homely setting, and only to be admitted to hospital when treatment is required that cannot be delivered in a community setting. This benefit is not necessarily immediate and can only be demonstrated through time.

As we approached the end of the first year, we reached capacity with our available staffing resources (current NHS staffing plus the addition of the Alzheimer Scotland Link Workers) to deliver PDS and have recruited to enable rollout across the city. This will be informed by the lessons learned from the initial phase of the project, such as the processes used for allocation of cases. In addition, we have developed recording systems (both electronic and patient-held), which will also be rolled out. We are likely to trial different models of PDS in other areas, in order to evaluate what appears to be the most efficient and effective.

The Evaluation Report is now available here.


Contacts - to find out more

Jill Carson, Jill.carson@nhs.net  0141 211 0650

Additional contact for further information:

Stephen Lithgow, Dementia Support & Development Worker, Stephen.lithgow@ggc.scot.nhs.uk