Improving dementia care through care navigation and social prescribing

NHS England | July 2018 | Improving dementia care through care navigation and social prescribing

A new case study from NHS England looks at an innovative approach to improving care for patients with dementia through navigation and social prescribing at a medical group in Gateshead. As  more people receiving a dementia diagnosis, senior nurses and GPs began to seek an alternative approach to the conventional ten-minute appointments. Many of these patients’ needs related to social care and wellbeing rather than acute clinical issues. Carers weren’t being identified and appropriate support wasn’t being received. Most case finding was undertaken by GPs and senior nurses. Some patients and carers were becoming frustrated, and the quality of care was at risk of being compromised.

This approach involved a  new way of working in which healthcare assistants (HCAs) are leading changes in practice to deliver a range of positive outcomes for both patients and carers, including increased access to health and social care services, improved dementia screening, individualised care plans and social prescribing.


Existing health care assistant (HCA) and receptionist roles were redesigned to undertake this function. Staff were trained to prepare them for the change.

The purpose of the Primary Care navigator role is to:

  • Communicate with patients and carers, asking questions and actively listening
  • Guide people to sources of help and support, from the most local to national
  • Support case-finding through clinical referrals and opportunistic screening
  • Develop a directory of services of third sector and other community support available for people with dementia and their carers

The practice has now extended the navigator role to support all social prescribing for patients with complex needs. It will be the foundation for implementing a ‘House of Care’ approach to long term conditions, to support self-care and self-management. Gateshead CCG has included the initiative in its primary care strategy.

(Source: NHS England )

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