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Organisation develops a service that offers a single point of access to support and care for dementia patients and carers, resulting in over 300 people registering for the service


    • Dementia patients and their carers consistently had to re-tell their story
    • Patients and carers were overwhelmed with information
    • No single point of contact to help navigate through support and services
    • Improve the quality of life of carers and people living with dementia


    • Initiated Dementia Together service, providing a single point of access to information and support for empowering carers and people with dementia
    • Provided advice and information appropriate to the user’s needs at the time of contact
    • Allowed registration on web-based information system to enable information sharing with other agencies
    • Created awareness of local community networks, voluntary sector etc


    • Resulted in over 300 people registering for the service


 Significant challenges arose from previous pathways were fed back to commissioners via workshops and through direct contact with carers, patients and services, including:

•patients/carers consistently having to re-tell their story

•patients/carers being overwhelmed with information

•no single point of contact to help navigate support and services

•agencies working ‘in silos’

 A service model was needed to help empower carers and people with dementia to easily identify and access the information and support they needed in order to plan for their future, avoid crises and live well with dementia for as long as possible in their usual place of residence.



 Workshops were held across Suffolk involving patients, carers, providers and commissioners prior to procurement. It was agreed that the new service would provide support to individuals and their carers diagnosed with, suspected of having or worried about dementia. There was a strong focus on person-centred care and supporting individuals along the whole pathway of care, multi-agency working and ensuring patients and carers did not have to repeat their story each time they were in contact with a service.

 The commissioned service - ‘Dementia Together’, led by Sue Ryder – employs a community asset based approach working with over 15 partners including statutory and voluntary organisations and Suffolk dementia action alliance. It offers a single point of access for people living with dementia, their families and carers via a dedicated helpline, and is delivered primarily through a team of dementia navigators.

The service delivers:

•personalised, high quality, consistent advice and information appropriate to the user’s needs at the time of contact

•complete understanding of Suffolk’s system-wide offer of services and systems of support

•help for users in understanding the condition, developing resilience and staying connected with their local community and networks

•awareness of the options available to users, including local community networks, local groups, the voluntary sector, statutory services, family and friends

•help in building resilience, confidence and the ability to make decisions for care, knowledge of what to do to live well and assistance in planning for their future and maintaining their independence for as long as possible

•registration on the web-based information system (with consent) to enable information sharing where appropriate with other agencies so users do not have to keep ‘retelling their story’

 The service is also a point of reference and advice for health and social care professionals, voluntary sector organisations and business and community leaders. Employees from the existing service were consulted and, where applicable, transfer of undertakings (Protection of Employment) across to ensure there was seamless care and a warm handover for all service users. Initiatives such as dementia friendly cafés were supported and developed in existing areas, whilst others evolved into larger groups where the numbers were small, enabling dementia navigators to continue supporting and building on existing relationships.

 The service has been jointly commissioned in partnership between Ipswich and East Suffolk CCG, West Suffolk CCG and Suffolk County Council. The contract value totals £228,000 between commissioners, with a 65%/35% health/local authority split.


 Since the service was launched in April 2017 over 300 people have registered. Attached is a case study, along with patient feedback, which highlights the support and innovation the dementia navigators and service can offer. More info in the attached document- HSJ2017_CCG AND LOCAL GOVERNMENT INTEGRATED COMMISSIONING FOR CARERS_DEMENTIA TOGETHER_02 CASE STUDY & PATIENT FEEDBACK


 A dementia navigator visited a couple following GP referral, which resulted in a referral to adult community services for carer’s assessment. Further concerns raised by the family resulted in the person living with dementia being referred to a frailty case worker and social worker, with navigator support. A joint mental health capacity review was also completed due to safeguarding issues raised; the case was handed to the dementia intensive support team with navigator support. The navigator continues to review the case with other agencies. Although challenging, working together has resulted in a multi-disciplinary team approach to their individual care.

More Information available in the attached document


Key individuals

Gail Cardy

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