Section 5 - Primary Care. August 2014 Needs Assessments... · Section(5(*(Primary(Care(! ......

1

Section(5(*(Primary(Care(

!

Primary!Care!is!that!care!which!would!normally!represent!a!patient’s!first!point!of!contact!with!healthcare!

services!in!the!community.!In!the!UK!it!is!generally!considered!to!be!general!practices!and!the!services!they!

provide.!!Usually,!primary!care!services!refer!on!to!secondary!care!services!provided!by!hospital!trusts.!

Since!April!2013,!Clinical!Commissioning!Groups!(CCGs)!overseen!by!the!newly!formed!NHS!England,!have!

been! act! as! statutory! NHS! bodies! responsible* for* commissioning* healthcare* services* for* their* local*

population! across! a! range! of! services!which!will! include! elective!hospital( care! and! community( services.!!

CCGs!have!a!duty!to!promote!the!involvement!of!individual!patients,!and!their!carers!and!representatives!in!

their!care!and!treatment!and!to!ensure!that!health!services!are!provided!in!an!integrated!way!with!social!

care!services,!where!this!will!improve!quality!of!services!or!reduce!inequalities.!

!The!Bradford!and!Airedale!locality!consists!of!three!CCGs;!

1. Airedale,!Wharfedale!and!Craven!CCG!(AWCCCG)!

2. Bradford!City!CCG!(BCCCG)!

3. Bradford!Districts!CCG!(BDCCG)!

(Dementia(in(Primary(Care(

It! is! important! to! realise! that! as!well! as! commissioning! services,! CCGs! are!organisations!made!up!of! the!

general! practices! that!provide!dayQtoQday!primary! care! in! the! community.!And! so,! alongside! this! familiar!

role,! as! commissioners!of!dementia! services,!CCGs!are! in!a!position! to!work!with!people!with!dementia,!

their!families!and!carers,!health!and!social!care!organisations!and!the!community!sector!to!develop!a!new!

dementia!landscape!in!which!services!are!able!to!meet!the!needs!of!local!communities!whilst!remaining!fair!

and!equitable.!

General!Practitioners!(GPs/family!doctors)!provide!the!majority!of!medical!care!for!people!with!dementia!(1),!and!an!adequate!primary!care!response!is!essential!to!quality!of!life!for!people!with!dementia!and!their!

families!(2).!The!roles!they!undertake!in!Bradford!and!Airedale!include:!

• Initial!diagnosis!Q!Use!of!brief!cognitive!assessment!tools!such!as!the!MiniQMental!State!Examination!

(MMSE)!allow!GPs!to!identify!possible!cases!of!dementia!in!primary!care!

• Basic! dementia! screens! performed! at! the! time!of! presentation,! usually!within! primary! care.! This!

generally!comprises!blood!tests!designed!to!exclude!any!other!causes!of!cognitive!impairment,!and!

to!assist!the!GP!and!colleagues!in!best!managing!the!patient!

• Ensuring! that! the! palliative! care! needs! of! people! with! dementia! who! are! close! to! death! are!

assessed! and! that! the! resulting! information! is! communicated!within! the! primary! care! team! and!

with!other!health!and!social!care!staff.!

• General!ongoing!support!for!both!patient!and!carer!

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The!point!at!which!a!diagnosis!is!made!in!primary!care!is!likely!to!be!the!start!of!a!period!in!which!greater!

demands!are!made!on! the!primary!and!secondary!healthcare! teams!and!also!on!social! care! (Rait),! and! the!

relationship!with!the!GP!and!GP!practice/staff!will!be!very!important!in!respect!of!both!dementia!and!the!

comorbidities!which!become!more!common!as!people!get!older.!

Research!has! identified! some!of! the! things! that! get! in! the!way!of!effective!primary! care! for!people!with!

dementia.! These! include! professionals! simply! not! understanding! the! importance! of! diagnosing! the!

condition!or!the!need!for!onQgoing!support!as!well!as!a!lack!of! information!for!people!with!dementia!and!

their!carers!about!the!condition!and!any!services!that!might!be!available!(2).!

!

Note:( *! The! CCGs! are! presented! here! in! turn,! outlining! key! demographic! information! and! dementia!

statistics!based!on!QoF!register!data!and!MATS!activity!figures.!Each!CCG!section!is!intended!to!be!viewed!

as!a!discrete!section!and!as!such!there!is!repetition!in!each.!

!

Note(*(Craven(

A!significant!issue!in!respect!of!the!geographical!area!covered!by!this!report!is!that!of!the!Craven!area,!and!

the! fact! that,! although! it! forms! part! of! AWCCCG,! it! is! not! part! of! the! BMDC! area.! As! such,! Craven! falls!

outside!of!the!responsibility!of!BMDC!and!the!Public!Health!Department,!being!covered!by!North!Yorkshire!

County!Council!and!the!Public!Health!Department!contained!therein.!

Following!discussions!with! the!AWCCCG!GP!Mental!Health! lead!and! the!Public!Health!Consultant!Mental!

Health!lead!in!North!Yorkshire!County!Council,!it!was!agreed!that:!

• It!was!felt!appropriate!to!limit!this!work!to!the!Bradford!Local!Authority!area!

• When!the!report!is!completed!it!will!be!discussed!with!the!Public!Health!Consultant!Mental!Health!

lead!in!North!Yorkshire!county!Council!to!facilitate!its!development!in!the!Craven!area.!

• In! instances!where!Craven!data!are!provided! in!the!same!packet!as!BMDC!area!data,!they!will!be!

included!alongside!given!no!further!data!sourcing!was!undertaken!

!

For!the!purposes!of!this!report,!the!following!annotation!will!be!used!

!

AWCCCG:!! Airedale,!Wharfedale!and!Craven!CCG,!encompassing!the!entire!CCG!

AWCCG:( The!proportion!of!the!CCG!lying!within!Local!Authority!boundaries( (

(

Note( *( Further( analyses( based( on( separation( of( the( two( elements( of( the( CCG( will( be( undertaken(

according(to(the(wishes(of(partners.(

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Airedale,(Wharfedale(and(Craven(Clinical(Commissioning(Group!

!

Key(Statistics(

• The! CCG’s! total! primary! care! registered! population! (taken! from! the!Attribution!Data! Set! in! April!

2011)!is!156,000!

• The! CCG's! registered! patients! live! in! 2! different! Local! Authorities,! Bradford! and! Craven! district!

Council!!

• The!CCG's!main!Local!Authority!is!Bradford.!67%!of!the!CCG's!population!live!there.!

• For!the!CCG's!main!Local!Authority,!Bradford,!the!CCG!accounts!for!104,500!(19%)!of!its!population.!

• This!CCG's!main!provider!is!Airedale!NHS!Foundation!Trust,!which!accounts!for!44,322!(79%)!of!its!

admissions.!These!represent!73%!of!that!provider's!total!admissions.!!

• 9%!of!admissions!go!to!BTHFT!and!5%!to!LTHT!

!

Dementia(

• The!CCG!has!1106! registered!patients!with!a!diagnosis!of!dementia,!0.71%!of!the!total!registered!

population!

• The! Airedale! &! Wharfedale! part! of! the! CCG! has! 672! registered! patients! with! a! diagnosis! of!

dementia,!0.64%!of!its!total!registered!population!

• Table! 1! below! set! out! age! stratified! population! projections! for! AWCCCG! up! to! 2021.! There! is! a!

projected!rise!in!the!60+!population!of!almost!6,000!from!2013!to!2021.(

(

Table(1((Age(Stratified((Population(Projections,(Airedale,(Wharfedale(and(Craven(CCG,(2011*2021(

Age 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Rise 2013-20210%9 18,887 19,256 19,611 19,990 20,318 20,555 20,795 20,960 21,145 21,312 21,537 1,92610%19 19,502 19,483 19,495 19,473 19,526 19,613 19,709 19,870 19,988 20,188 20,363 86820%29 15,687 15,901 16,109 16,328 16,514 16,765 16,974 17,108 17,236 17,268 17,196 1,08730%39 18,226 18,148 18,203 18,316 18,460 18,646 18,846 19,090 19,216 19,301 19,471 1,26740%49 23,326 23,421 23,389 23,267 23,144 22,970 22,696 22,495 22,415 22,376 22,266 ,1,12350%59 21,181 21,516 21,793 22,077 22,406 22,610 22,851 22,970 23,155 23,316 23,500 1,70660%69 19,469 19,970 20,387 20,715 21,069 21,448 21,204 21,245 21,425 21,682 22,034 1,64770%79 12,817 12,753 12,823 12,947 12,984 13,082 13,736 14,223 14,651 14,990 15,387 2,56480%89 7,636 7,672 7,676 7,772 7,915 8,042 8,228 8,432 8,551 8,683 8,705 1,029 60+0Rise90+ 1,597 1,708 1,821 1,922 1,993 2,073 2,146 2,211 2,300 2,406 2,523 702 5,942Total 158,328 159,828 161,309 162,807 164,328 165,803 167,185 168,605 170,081 171,522 172,982 11,673

!

Note:(

The!CCG's! geographical! area! is!made!up!of! 97! LSOAs.! The! total! population!of! these! LSOAs! is!162,737! of!

which!153,797!are!registered!with!this!CCG's!practices.!The!total!registered!population!of!the!CCG!practices!

is!155,565.!

Therefore,!there!are!8,941!people!who!are!registered!with!other!CCG's!practices!but!live!in!this!CCG's!area.!

But! there! are! 1,768! of! this! CCG's! registered! population! who! live! in! other! CCG's! area! of! geographical!

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responsibility.! This! gives! a! ‘containment! rate’! (i.e.! percentage! of! registered! patients!who! live!within! the!

geographical!boundary!of!the!CCG)!of!98.9%!

(

Primary(Care(Services(for(Dementia(

• The!CCG!has!17!general!practices,!based!on!those!with!a!registered!population!in!April!2011!

• The!Airedale!&!Wharfedale!part!of!the!CCG!has!12!general!practices!

• All!patents!receive!general!medical!services!as!specified! in!the!General!Medical!Services/Personal!

Medical!Services!contracts!

• Dementia!Diagnoses!and!Reviews!are!provided!under!the!Quality!and!Outcomes!Framework!

• The! CCG! has! appointed! a! Clinical! Lead! for! Mental! Health,! Dr! Brendan! Kennedy,! who! provides!

leadership,! expertise! and! advocacy! for! patients!with! dementia! through! partnership!working! and!

representation!at!strategic!committees!

• CCG!practices! use! the! SystmOne!electronic!medical! record! system! to! record! information! in! both!

people!with!dementia!and!their!carers!as!part!of!ongoing!work!to!secure!effective!integrated!care!

for!these!people.!

!

Figure! 1! below! shows! AWCCCG! within! its! geographical! boundary,! with! the! changing! containment! rates!

shown!across!various!geographical!areas!both!within!and!without!this!boundary.!This!gives!an!indication!of!

the! “bleed”!of! registered!patients! across! the!CCG!boundaries! (as! set! out! in! the! legend!below).! The! gold!

stars!within!the!CCG!boundary!indicate!the!geographical!location!of!the!CCG’s!general!practices.!

(

(

(

(

(

(

(

(

(

(

(

(

(

(

(

(

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Figure(1(((((((Geographical(Location(of(Airedale,(Wharfedale(and(Craven(CCG(and(Practices,(2013(

(

Practice(Level(Prevalence(Rates(for(Dementia(

This!section!sets!out,!by!general!practice,!the!numbers!of!patients!who!are!on!the!QoF!register!as!having!a!

diagnosis! of! dementia.! These! numbers! are! also! represented! as! a! prevalence/proportion! of! the! overall!

practice!population,!with!95%!confidence!intervals!added.!The!confidence!intervals!are!included!in!order!to!

allow! for! the!variation!and!chance! that! can!occur!according! to!practice! size,!where! smaller!practices!are!

more!prone! to! the! impact! of! chance.! It! is! reasonable! to! assume! that! there! is! a! 19/20!probability! that! a!

‘true’! or! reasonable!estimate!of! each!practice!prevalence! lies! somewhere!between! the!upper! and! lower!

confidence!limits!shown.!

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Numbers!of!patients!with!dementia!are!presented!as!a!proportion!of!the!overall!practice!population!as!this!

reflects!the!national!approach!to!measuring!prevalence!as!in!the!recently!published!Department!of!Health!

Dementia!Map!(3).!

It! is! important!to!recognise!that!this!section! is!not!a!performance!management!tool!and!as!such!practice!

identities! are! anonymised.! ! It! is! intended! that! this! section!will! inform! those! involved! in! primary! care! in!

respect! of! heterogeneity! of! diagnosis! rates,! it! is! not! intended! to! be! used! to! facilitate! interQpractice!

comparisons.! Given! this! important! note,! it! was! decided! not! to! age! standardise! the! practices! as! the!

intention! is! to! present! the! reality! of! diagnostic! activity,! and! age! standardising! in! smaller! practice!

populations!would!have!presented!methodological!difficulties.!!

!

There!are!a!number!of!important!caveats!to!bear!in!mind!at!this!point:!

• Cannot!include!mortalities!who!will!be!taken!off!the!list!

• This!analysis!represents!a!snapshot!May!have!already!picked!up!most!

• Likely!to!generate!other!analytical!pieces!of!work!

• Recommend!clinical!audit!

!

Table!2!and!Figure!2!below!set!out!the!diagnostic!prevalence!of!dementia,!at!practice!level,!for!the!Airedale!

and! Wharfedale! component! of! AWCCCG,! with! Table! 3! and! Figure! 3! providing! the! same! for! AWCCG!

Diagnostic!prevalence!here! is! represented!by!diagnoses!recorded!on!the!Primary!Care!QoF!Register!as!at!

November!2013,!with!the!total!practice!population!as!denominator.!95%!confidence!limits!are!calculated!in!

addition,!as!explained!above.!!

!

Key(Observations(

• The!overall!prevalence!of!dementia!in!AWCCCG!is!0.71%,!with!95%!limits!from!0.67%!to!0.75%!

• The!overall! prevalence!of! dementia! in! the!AWCCG!area! is!0.64%,!with!95%! limits! from!0.59%! to!

0.69%!!

• The!prevalence!for!both!AWCCCG!and!the!AWCCG!area!is!higher!than!in!the!three!comparators!of!

England,!UK!and!North!of!England!Commissioning!Group,!with!confidence!limits!suggesting!that!this!

is!a!statistically!significant!increase!for!both!

• There! is!notable!heterogeneity!across!practices!for!both!AWCCCG!and!AWCCG!with!suggestion!of!

statistically!significant!difference!between!many!practices!

• There!is!one!notable!outlier!at!the!lower!diagnostic!extremity!for!both!AWCCCG!and!AWCCG!

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Table(2(((Prevalence(of(Dementia(Diagnosis(as(%,(Airedale,(Wharfedale(and(Craven(CCG,(2013(

Organisation ID Numerator Denominator % 95% LCL 95% UCL Centile

AWCCCG 1106 155635 0.71% 0.67% 0.75% 90

England N/A 291677 55068625 0.53% N/A N/A N/A

UK N/A 358577 65266344 0.55% N/A N/A N/A

North of England Commissioning Group N/A 91314 15694547 0.58% N/A N/A 100

1 51 4098 1.24% 0.94% 1.63% 96

2 54 4525 1.19% 0.91% 1.55% 95

3 129 12169 1.06% 0.89% 1.26% 93

4 132 13061 1.01% 0.85% 1.20% 91

5 78 9225 0.85% 0.68% 1.06% 85

6 89 10644 0.84% 0.68% 1.03% 85

7 91 11663 0.78% 0.64% 0.96% 82

8 49 6539 0.75% 0.57% 0.99% 80

9 84 13254 0.63% 0.51% 0.78% 69

10 20 3209 0.62% 0.40% 0.96% 68

11 85 13918 0.61% 0.49% 0.75% 67

12 67 11229 0.60% 0.47% 0.76% 65

13 57 9788 0.58% 0.45% 0.75% 63

14 65 12614 0.52% 0.41% 0.66% 55

15 12 2928 0.41% 0.23% 0.72% 40

16 37 9330 0.40% 0.29% 0.55% 38

17 6 7441 0.08% 0.04% 0.17% 3 !

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Table(3((((((((Prevalence(of(Dementia(Diagnosis(as(%,(Airedale(and(Wharfedale(CCG(Area,(2013(


AWCCG N/A 672 104562 0.64% 0.59% 0.69% N/A

England N/A 291677 55068625 0.53% 0.53% 0.53% N/A

UK N/A 358577 65266344 0.55% 0.55% 0.55% N/A

North of England Commissioning Group N/A 91314 15694547 0.58% 0.58% 0.58% 100

1 54 4525 1.19% 0.91% 1.55% 95

2 132 13061 1.01% 0.85% 1.20% 91

3 89 10644 0.84% 0.68% 1.03% 85

4 49 6539 0.75% 0.57% 0.99% 80

5 84 13254 0.63% 0.51% 0.78% 69

6 20 3209 0.62% 0.40% 0.96% 68

7 67 11229 0.60% 0.47% 0.76% 65

8 57 9788 0.58% 0.45% 0.75% 63

9 65 12614 0.52% 0.41% 0.66% 55

10 12 2928 0.41% 0.23% 0.72% 40

11 37 9330 0.40% 0.29% 0.55% 38

12 6 7441 0.08% 0.04% 0.17% 3 !!

!

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!

Figure'2''''''''''''''''''''''''''''''''''''''Prevalence'of'Dementia'Diagnosis'as'%,'with'95%'C.I.,'Airedale,'Wharfedale'and'Craven'CCG,'2013'

0.00%

0.20%

0.40%

0.60%

0.80%

1.00%

1.20%

1.40%

1.60%

1.80%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Practice

% w

ith

Dem

enti

a D

iagn

osis

!

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Figure'3'''''''''''''''''''''''''''''''''''''Prevalence'of'Dementia'Diagnosis'as'%,'with'95%'C.I.,'Airedale'and'Wharfedale'CCG'Area,'2013'

0.00%

0.20%

0.40%

0.60%

0.80%

1.00%

1.20%

1.40%

1.60%

1.80%

1 2 3 4 5 6 7 8 9 10 11 12

Practice

% w

ith

Dem

entia

Dia

gnos

is

!!

!

Memory'Assessment'and'Treatment'Services'Referral'Rates'

This%section%provides%an%over%view%of%the%extent%to%which%people%in%the%CCG%area%who%have%dementia%are%

referred%to%a%Memory%Assessment%and%Treatment%Services%(MATS).%

%

Note:%

• Section%6b%covers%Memory%Assessment%and%treatment%Services%in%detail%

• Comparison%with%other%CCGs%in%the%District%is%provided%in%Section%6b%

• MATS%data%are%not%currently%available%for%Craven%so%what%is%presented%here%is%for%AWCCG%only%

%

Tables%4%and%5%and%Figures%4%and%5%demonstrate%how%both%numbers%of%referrals%and%the%rate%of%referral%per%

1,000%registered%people%have%changed%since%2005.%

'

Key'Observations'

• Both%numbers%and%rates%of%referral%have%risen%steadily%from%2005%up%to%2012.%%

• There%is%a%notable%drop%off%in%2013%

• There%was%a%sharp%upturn%in%2010%which%may%reflect%changes%to%data%recording%processes%relating%to%

the%introduction%of%the%SystmOne%patient%database%in%primary%care%

%

Table'4'''''''''Referrals'to'Memory'Assessment'and'Treatment'Services,'AWCCG'2005A2013'

Referrals to MATS

2005-2006 5

2006-2007 9

2007-2008 13

2008-2009 27

2009-2010 38

2010-2011 47

2011-2011 106

2012-2013 104

Grand Total 349%

%

%

%

%

12

%

Figure'4''''Referrals'to'Memory'Assessment'and'Treatment'Services,'AWCCG'2005A2013'

%

0

20

40

60

80

100

120

2005-2006 2006-2007 2007-2008 2008-2009 2009-2010 2010-2011 2011-2011 2012-2013

Num

ber

Year %

%

%

Table'5''''Rates'of'Referrals'to'Memory'Assessment'and'Treatment'Services,'AWCCG'2005A2013'

Referrals to MATS - Rate/1,000

2005-2006 0.0

2006-2007 0.1

2007-2008 0.1

2008-2009 0.3

2009-2010 0.4

2010-2011 0.5

2011-2012 1.1

2012-2013 1.0%

%

%

%

%

%

%

13

%

Figure'5''Rates'of'Referrals'to'Memory'Assessment'and'Treatment'Services,'AWCCG'2005A2013'

%

0.0

0.2

0.4

0.6

0.8

1.0

1.2

2005-2006 2006-2007 2007-2008 2008-2009 2009-2010 2010-2011 2011-2012 2012-2013

Rat

e pe

r 1,0

00

Year

Bradford'Districts'Clinical'Commissioning'Group'

%Key'Statistics'

• The% CCG’s% total% primary% care% registered% population% (taken% from% the%Attribution%Data% Set% in% April%

2011)%is%328,000%

• The%compares%to%an%average%for%all%212%CCGs%in%England%of%261,000.%

• The%CCG's%registered%patients%live%in%4%different%upper%tier%Local%Authorities,%Bradford,%XXX%

• The%CCG's%main%Local%Authority%is%Bradford,%with%98%%of%the%CCG's%population%living%there.%

• For% the% CCG's% main% Local% Authority,% Bradford,% this% CCG% accounts% for% 320,300% (58%)% of% its%

population.%

• The% CCG's%main% provider% is% Bradford% Teaching% Hospitals% NHS% Foundation% Trust% and% accounts% for%

78,703%(76%)%of%its%admissions.%These%represent%67%%of%that%provider's%total%admissions.%

'Dementia'

• The%CCG%has%2007% registered%patients%with%a%diagnosis%of%dementia,%0.61%%of%the%total%registered%

population%

• Table% 6% below% sets% out% age% stratified% population% projections% for% BDCCG% up% to% 2021.% There% is% a%

projected%rise%in%the%60+%population%of%almost%9,000%from%2013%to%2021.'

%

Table'6'''''''''''''Age'Stratified''Population'Projections,'Bradford'Districts'CCG,'2011A2021'

Age 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Rise 2013-20210"9 49,149 50,110 51,052 52,065 52,903 53,491 54,123 54,561 55,018 55,409 55,938 4,88610"19 45,078 45,025 45,063 44,998 45,133 45,338 45,569 45,946 46,225 46,673 47,068 2,00520"29 44,968 45,534 46,114 46,713 47,250 47,971 48,621 49,021 49,406 49,509 49,320 3,20630"39 45,689 45,599 45,791 46,112 46,475 46,882 47,294 47,844 48,162 48,430 48,916 3,12540"49 46,032 46,218 46,122 45,837 45,550 45,176 44,628 44,250 44,147 44,144 43,987 "2,13550"59 39,114 39,744 40,262 40,797 41,373 41,749 42,186 42,402 42,730 43,019 43,347 3,08660"69 29,812 30,476 31,079 31,574 32,053 32,665 32,355 32,448 32,740 33,136 33,678 2,59970"79 19,879 19,763 19,888 20,073 20,124 20,281 21,325 22,093 22,683 23,278 23,894 4,00680"89 10,742 10,788 10,791 10,938 11,132 11,311 11,584 11,864 12,014 12,190 12,200 1,408 60+'Rise90+ 1,957 2,093 2,232 2,355 2,442 2,540 2,629 2,709 2,818 2,948 3,092 860 8,873Total 332,420 335,351 338,394 341,463 344,436 347,404 350,316 353,137 355,942 358,736 361,439 23,046

'

Note:'

The%CCG's%geographical%area% is%made%up%of%198%LSOAs.%The%total%population%of% these%LSOAs% is%346,102%of%

which%286,424%are%registered%with%this%CCG's%practices.%The%total%registered%population%of%the%CCG%practices%

is%327,877.%%

Therefore,%there%are%59,678%people%who%are%registered%with%other%CCG's%practices%but%live%in%the%CCG's%area.%

But% there% are% 41,453% of% this% CCG's% registered% population% who% live% in% other% CCG's% area% of% geographical%

responsibility.% This% gives% a% ‘containment% rate’% (i.e.% percentage% of% registered% patients%who% live%within% the%

geographical%boundary%of%the%CCG)%of%87.4%%

15

Primary'Care'Services'for'Dementia'

• The%CCG%has%42%practices,%based%on%those%with%a%registered%population%in%April%2011.%

• All%patents%receive%general%medical%services%as%specified% in%the%General%Medical%Services/Personal%

Medical%Services%contracts%

• Dementia%Diagnoses%and%Reviews%are%provided%under%the%Quality%and%Outcomes%Framework%

• The% CCG% has% appointed% a% Clinical% Lead% for% Mental% Health,% Dr% Sara% Humphrey,% who% provides%

leadership,% expertise% and% advocacy% for% patients%with% dementia% through% partnership%working% and%

representation%at%strategic%committees%

• The% CCG% has% a% clinical% board%member% responsible% for% mental% health% and% dementia,% Dr%Waheed%

Hussain,%and%have%also%appointed%a%GP%with%special%interest%in%older%people%to%be%a%'clinical%specialty%

lead,%again%Dr%Sara%Humphrey%

• CCG%practices% use% the% SystmOne%electronic%medical% record% system% to% record% information% in% both%

people%with%dementia%and%their%carers%as%part%of%ongoing%work%to%secure%effective%integrated%care%

for%these%people.%

%

Figure%6%below%shows%BDCCG%within%its%geographical%boundary,%with%the%changing%containment%rates%shown%

across% various% geographical% areas%both%within% and%without% this% boundary.% This% gives% an% indication%of% the%

“bleed”% of% registered% patients% across% the% CCG% boundaries% (as% set% out% in% the% legend% below).% The% silver%

inverted% triangles% within% the% CCG% boundary% indicate% the% geographical% location% of% the% CCG’s% general%

practices.%

'

'

'

'

'

'

'

'

'

'

'

'

'

'

'

'

16

Figure'6'''''''''''''''Geographical'Location'of'Bradford'Districts'CCG'and'Practices,'2013'

%%

Practice'Level'Prevalence'Rates'for'Dementia'

This%section%sets%out,%by%general%practice,%the%numbers%of%patients%who%are%on%the%QoF%register%as%having%a%

diagnosis% of% dementia.% These% numbers% are% also% represented% as% a% prevalence/proportion% of% the% overall%

practice%population,%with%95%%confidence%intervals%added.%The%confidence%intervals%are%included%in%order%to%

allow% for% the%variation%and%chance% that% can%occur%according% to%practice% size,%where% smaller%practices%are%

more%prone% to% the% impact% of% chance.% It% is% reasonable% to% assume% that% there% is% a% 19/20%probability% that% a%

‘true’% or% reasonable%estimate%of% each%practice%prevalence% lies% somewhere%between% the%upper% and% lower%

confidence%limits%shown.%

17

Numbers%of%patients%with%dementia%are%presented%as%a%proportion%of%the%overall%practice%population%as%this%

reflects%the%national%approach%to%measuring%prevalence%as%in%the%recently%published%Department%of%Health%

Dementia%Map%(3).%

It% is% important%to%recognise%that%this%section% is%not%a%performance%management%tool%and%as%such%practice%

identities% are% anonymised.% % It% is% intended% that% this% section%will% inform% those% involved% in% primary% care% in%

respect% of% heterogeneity% of% diagnosis% rates,% it% is% not% intended% to% be% used% to% facilitate% interfpractice%

comparisons.% Given% this% important% note,% it% was% decided% not% to% age% standardise% the% practices% as% the%

intention% is% to% present% the% reality% of% diagnostic% activity,% and% age% standardising% in% smaller% practice%

populations%would%have%presented%methodological%difficulties.%%

%

There%are%a%number%of%important%caveats%to%bear%in%mind%at%this%point:%

• Cannot%include%mortalities%who%will%be%taken%off%the%list%

• This%analysis%represents%a%snapshot%May%have%already%picked%up%most%

• Likely%to%generate%other%analytical%pieces%of%work%

• Recommend%clinical%audit%

%

Table% 7% and% Figure% 7% below% set% out% the%diagnostic% prevalence%of% dementia,% at% practice% level,% for% BDCCG.%

Diagnostic%prevalence%here% is% represented%by%diagnoses%recorded%on%the%Primary%Care%QoF%Register%as%at%

November%2013,%with%the%total%practice%population%as%denominator.%95%%confidence%limits%are%calculated%in%

addition,%as%explained%above.%%

%

Key'Observations'

• The%overall%prevalence%of%dementia%in%BDCCG%is%0.61%,%with%95%%limits%from%0.58%%to%0.64%%

• The% prevalence% is% higher% than% in% the% three% comparators% of% England,% UK% and% North% of% England%

Commissioning% Group,% with% confidence% limits% suggesting% that% this% is% a% statistically% significant%

increase%

• There% is% moderate% heterogeneity% across% practices% with% suggestion% of% statistically% significant%

difference%between%some%practices%at%the%extremes%of%variation%

• Much%of%the%observed%variation%between%practices%is%not%statistically%significant%

• There%is%one%notable%outlier%at%the%upper%diagnostic%extremity%

18

Table'7''''''''''''''''''Prevalence'of'Dementia'Diagnosis'as'%,'Bradford'Districts'CCG','2013'


Bradford Districts CCG N/A 2007 330270 0.61% 0.58% 0.64% 2


UK N/A 358577 65266344 0.55% N/A N/A N/A


West Yorkshire Local Area Team N/A 12006 2259773 0.53% N/A N/A 37

1 103 3342 3.08% 2.53% 3.74% 99

2 48 3765 1.27% 0.96% 1.68% 96

3 85 7562 1.12% 0.91% 1.38% 94

4 60 6799 0.88% 0.68% 1.13% 87

5 76 9081 0.84% 0.68% 1.06% 85

6 63 8059 0.78% 0.61% 1.00% 82

7 51 6579 0.78% 0.59% 1.02% 81

8 37 4923 0.75% 0.54% 1.03% 80

9 77 10721 0.72% 0.58% 0.90% 77

10 63 8783 0.72% 0.56% 0.92% 77

11 83 11612 0.71% 0.57% 0.88% 77

12 77 10825 0.71% 0.57% 0.89% 76

13 69 9848 0.70% 0.55% 0.88% 75

14 56 8035 0.70% 0.54% 0.91% 75

15 38 5497 0.69% 0.50% 0.95% 75

16 72 10496 0.69% 0.55% 0.87% 74

17 82 12111 0.68% 0.55% 0.84% 73

18 50 8125 0.62% 0.47% 0.82% 67

19 60 9814 0.61% 0.47% 0.78% 67

20 18 3021 0.60% 0.38% 0.95% 65

21 22 3898 0.56% 0.37% 0.85% 61

22 40 7200 0.56% 0.41% 0.76% 60

23 134 25090 0.53% 0.45% 0.63% 58

24 34 6535 0.52% 0.37% 0.73% 56

25 36 7057 0.51% 0.37% 0.71% 54

26 34 6841 0.50% 0.36% 0.70% 53

27 55 11072 0.50% 0.38% 0.65% 52

28 39 8046 0.48% 0.35% 0.66% 51

29 56 12155 0.46% 0.35% 0.60% 47

30 41 9191 0.45% 0.33% 0.61% 45

31 37 8346 0.44% 0.32% 0.61% 45

32 29 6619 0.44% 0.31% 0.63% 44

33 31 7179 0.43% 0.30% 0.61% 43

34 32 7752 0.41% 0.29% 0.58% 41

35 30 8231 0.36% 0.25% 0.51% 34

36 12 3735 0.32% 0.18% 0.56% 28

37 32 11066 0.29% 0.21% 0.41% 24

38 15 5614 0.27% 0.16% 0.44% 21

39 12 4758 0.25% 0.14% 0.44% 19

40 14 7582 0.18% 0.11% 0.30% 11

41 <5 3305 #VALUE! 0.05% 0.33% 6 %

Figure'7''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''Prevalence'of'Dementia'Diagnosis'as'%,'Bradford'Districts'CCG,'2013'

'

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

4.00%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41

Practice

% w

ith

Dem

entia

Dia

gnos

is




%

Note:%



%

Tables%8%and%8%and%Figures%9%and%9%demonstrate%how%both%numbers%of%referrals%and%the%rate%of%referral%per%

1,000%registered%people%have%changed%since%2005.%

'

Key'Observations'

• Both%numbers%and%rates%of%referral%have%risen%steadily%from%2005%up%to%2013.%%

• There%is%a%suggestion%that%the%rate%of%rise%has%tailed%off%slightly%in%2012O13%%

• There%was%an%upturn%in%2010%which%may%reflect%changes%to%data%recording%processes%relating%to%the%

introduction%of%the%SystmOne%patient%database%in%primary%care%

%

%

Table'8''''''''Referrals'to'Memory'Assessment'and'Treatment'Services,'BDCCG'2005B2013'

Referrals to MATS

2005-2006 18

2006-2007 41

2007-2008 81

2008-2009 140

2009-2010 194

2010-2011 330

2011-2011 493

2012-2013 592

Grand Total 1889%

%

%

%

%

%

21

Figure'8'''''''Numbers'of'Referrals'to'Memory'Assessment'and'Treatment'Services,'BDCCG'2013'

0

100

200

300

400

500

600

700

2005-2006 2006-2007 2007-2008 2008-2009 2009-2010 2010-2011 2011-2011 2012-2013

Year

Number

%

%

%

Table'9''''''''''''Rates'of'Referrals'to'Memory'Assessment'and'Treatment'Services,'BDCCG'2013'


2005-2006 0.1

2006-2007 0.1

2007-2008 0.2

2008-2009 0.4

2009-2010 0.6

2010-2011 1.0

2011-2012 1.5

2012-2013 1.8%

%

%

%

%

%

%

%

%

%

22

Figure'9''''''''''Rates'of'Referrals'to'Memory'Assessment'and'Treatment'Services,'BDCCG'2013'

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

2.0

2005-2006 2006-2007 2007-2008 2008-2009 2009-2010 2010-2011 2011-2012 2012-2013

Year

Rate

per

1,0

00

23

Bradford'City'Clinical'Commissioning'Group'

%

Key'Statistics'

• The%CCG’s% total% registered%population% (taken% from%the%Attribution%Data%Set% in%April%

2011)%is%118,000%

• This%compares%to%an%average%for%all%212%CCGs%in%England%of%261,000%

• This% CCG's% registered% patients% all% live% in% one% upper% tier% Local% Authority,% this% Local%

Authority%is%Bradford%

• For%the%CCG's%main%Local%Authority,%Bradford,%the%CCG%accounts%for%117,300%(21%)%of%

its%population.%

• The%CCG's%main%provider% is%Bradford%Teaching%Hospitals%NHS%Foundation%Trust%and%

accounts%for%25,338%89%)%of% its%admissions.%These%represent%22%%of%that%provider's%

total%admissions.%

'

Dementia'

• The%CCG%has%281%registered%patients%with%a%diagnosis%of%dementia,%0.24%%of%the%total%

registered%population%

• Table%x%below%sets%out%age%stratified%population%projections%for%BCCCG%up%to%2021.%

There%is%a%projected%rise%in%the%60+%population%of%1,153%from%2013%to%2021.'

'

Table'10''''''''Age'Stratified''Population'Projections,'Bradford'City'CCG,'2011B2021'Age 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Rise 2013-2021

0%9 15,409 15,719 16,017 16,339 16,595 16,788 16,978 17,111 17,241 17,362 17,522 1,50510%19 13,081 13,057 13,078 13,060 13,120 13,158 13,231 13,349 13,392 13,499 13,604 52620%29 17,749 18,016 18,265 18,511 18,713 18,985 19,205 19,337 19,468 19,487 19,385 1,12030%39 13,281 13,282 13,350 13,448 13,559 13,676 13,776 13,912 14,003 14,090 14,245 89540%49 8,270 8,306 8,278 8,211 8,144 8,061 7,947 7,870 7,864 7,898 7,903 ,37550%59 6,164 6,262 6,343 6,427 6,522 6,582 6,651 6,686 6,737 6,784 6,836 49360%69 3,564 3,638 3,711 3,759 3,832 3,920 3,881 3,895 3,927 3,973 4,037 32670%79 2,658 2,640 2,655 2,684 2,695 2,711 2,859 2,977 3,060 3,126 3,203 54880%89 1,316 1,321 1,321 1,337 1,363 1,386 1,419 1,454 1,470 1,487 1,491 170 60+0Rise90+ 249 266 284 300 311 323 335 345 359 375 393 109 1,153Total 81,741 82,508 83,302 84,075 84,854 85,591 86,283 86,935 87,522 88,081 88,619 5,317 '

'

Note:'

This%CCG's%geographical%area%is%made%up%of%41%LSOAs.%The%total%population%of%these%LSOAs%is%

91,891% of% which% 60,676% are% registered% with% this% CCG's% practices.% The% total% registered%

population%of%the%CCG%practices%is%117,990.%

24

Therefore,%there%are%31,215%people%who%are%registered%with%other%CCG's%practices%but%live%in%

this%CCG's%area.%But% there%are%57,314%of% this%CCG's% registered%population%who% live% in%other%

CCG's%area%of%geographical%responsibility.%

This% gives% a% ‘containment% rate’% (i.e.% percentage% of% registered% patients%who% live%within% the%

geographical%boundary%of%the%CCG)%of%51.4%.%

'

Primary'Care'Services'for'Dementia'

• This%CCG%has%29%practices,%based%on%those%with%a%registered%population%in%April%2011.%

• All% patents% receive% general% medical% services% as% specified% in% the% General% Medical%

Services/Personal%Medical%Services%contracts%

• Dementia% Diagnoses% and% Reviews% are% provided% under% the% Quality% and% Outcomes%

Framework%

• The%CCG%has%appointed%a%Clinical% Lead% for%Mental%Health,%Dr%Sara%Humphrey,%who%

provides% leadership,% expertise% and% advocacy% for% patients% with% dementia% through%

partnership%working%and%representation%at%strategic%committees%

• The%CCG%has%a%clinical%board%member%responsible% for%mental%health%and%dementia,%

Dr%Waheed% Hussain,% and% have% also% appointed% a% GP% with% special% interest% in% older%

people%to%be%a%'clinical%specialty%lead,%again%Dr%Sara%Humphrey%

• CCG% practices% use% the% SystmOne% electronic% medical% record% system% to% record%

information%in%both%people%with%dementia%and%their%carers%as%part%of%ongoing%work%

to%secure%effective%integrated%care%for%these%people.%

%

Figure% 10% below% shows% BDCCG% within% its% geographical% boundary,% with% the% changing%

containment% rates% shown% across% various% geographical% areas% both% within% and% without% this%

boundary.% This% gives% an% indication% of% the% “bleed”% of% registered% patients% across% the% CCG%

boundaries% (as% set% out% in% the% legend% below).% The% green% stars% within% the% CCG% boundary%

indicate%the%geographical%location%of%the%CCG’s%general%practices.%

'

%

%

'

'

'

'

25

Figure'10''''''''''Geographical'Location'of'Bradford'City'CCG'and'Practices,'2013'

%

'

Practice'Level'Prevalence'Rates'for'Dementia'

This% section% sets% out,% by% general% practice,% the% numbers% of% patients% who% are% on% the% QoF%

register% as% having% a% diagnosis% of% dementia.% These% numbers% are% also% represented% as% a%

prevalence/proportion% of% the% overall% practice% population,% with% 95%% confidence% intervals%

added.%The%confidence%intervals%are%included%in%order%to%allow%for%the%variation%and%chance%

that% can% occur% according% to% practice% size,% where% smaller% practices% are%more% prone% to% the%

impact%of%chance.%It%is%reasonable%to%assume%that%there%is%a%19/20%probability%that%a%‘true’%or%

reasonable% estimate% of% each% practice% prevalence% lies% somewhere% between% the% upper% and%

lower%confidence%limits%shown.%

26

Numbers% of% patients%with% dementia% are% presented% as% a% proportion% of% the% overall% practice%

population%as%this%reflects%the%national%approach%to%measuring%prevalence%as%in%the%recently%

published%Department%of%Health%Dementia%Map%(3).%

It%is%important%to%recognise%that%this%section%is%not%a%performance%management%tool%and%as%

such% practice% identities% are% anonymised.% % It% is% intended% that% this% section%will% inform% those%

involved%in%primary%care%in%respect%of%heterogeneity%of%diagnosis%rates,%it%is%not%intended%to%

be%used% to% facilitate% interOpractice% comparisons.%Given% this% important%note,% it%was%decided%

not% to%age%standardise% the%practices%as% the% intention% is% to%present% the%reality%of%diagnostic%

activity,% and% age% standardising% in% smaller% practice% populations% would% have% presented%

methodological%difficulties.%%

%

There%are%a%number%of%important%caveats%to%bear%in%mind%at%this%point:%

• We%cannot%include%mortalities%who%will%be%taken%off%the%list%

• This% analysis% represents% a% snapshot% –% some% practices%may% have% “mopped% up”% the%

majority%of%their%cases%%%

%

Table% 11% and% Figure% 11% below% set% out% the% diagnostic% prevalence% of% dementia,% at% practice%

level,% for%BCCCG.%Diagnostic%prevalence%here% is% represented%by%diagnoses% recorded%on% the%

Primary% Care% QoF% Register% as% at% November% 2013,% with% the% total% practice% population% as%

denominator.%95%%confidence%limits%are%calculated%in%addition,%as%explained%above.%%

%

Key'Observations'

• The%overall%prevalence%of%dementia%in%BDCCG%is%0.24%,%with%95%%limits%from%0.21%%

to%0.27%%

• The%prevalence%is%markedly%lower%than%in%the%three%comparators%of%England,%UK%and%

North% of% England% Commissioning% Group,% with% confidence% limits% clearly% indicating%

that%this%is%a%statistically%significant%difference%

• There% is%moderate% heterogeneity% across% practices%with% little% statistically% significant%

difference%between%practices%

• There%is%one%notable%outlier%at%the%upper%diagnostic%extremity%and%two%at%the%lower%

extremity%

27

Table'11''''Prevalence'of'Dementia'Diagnosis'as'%,'Bradford'Districts'CCG','2013'


Bradford City CCG N/A 281 118636 0.24% 0.21% 0.27% 75


UK N/A 358577 65266344 0.55% N/A N/A N/A


1 52 5334 0.97% 0.74% 0.97% 99

2 51 8776 0.58% 0.44% 0.76% 96

3 13 2578 0.50% 0.29% 0.86% 94

4 23 6072 0.38% 0.23% 0.57% 87

5 8 2581 0.31% 0.16% 0.61% 85

6 7 2454 0.29% 0.14% 0.59% 82

7 5 1807 0.28% 0.12% 0.65% 81

8 6 2250 0.27% 0.12% 0.59% 80

9 11 4132 0.27% 0.15% 0.48% 77

10 6 2394 0.25% 0.11% 0.54% 77

11 11 4646 0.24% 0.13% 0.43% 77

12 8 3474 0.23% 0.12% 0.45% 76

13 11 4827 0.23% 0.13% 0.41% 75

14 6 2963 0.20% 0.09% 0.44% 75

15 7 3868 0.18% 0.09% 0.37% 75

16 11 6160 0.18% 0.10% 0.32% 74

17 7 4317 0.16% 0.08% 0.33% 73

18 6 3923 0.15% 0.07% 0.33% 67

19 7 5166 0.14% 0.07% 0.29% 67

20 2 1523 0.13% 0.04% 0.48% 65

21 8 6429 0.12% 0.06% 0.24% 61

22 4 3327 0.12% 0.05% 0.31% 60

23 2 1760 0.11% 0.03% 0.41% 58

24 3 2970 0.10% 0.03% 0.30% 56

25 5 7647 0.07% 0.03% 0.16% 54

26 1 4813 0.02% 0.00% 0.12% 53

27 0 10846 0.00% N/A N/A 52

28 0 1599 0.00% N/A N/A 51

28

Figure'11''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''Prevalence'of'Dementia'Diagnosis'as'%,'Bradford'Districts'CCG','2013'

'

0.00%

0.20%

0.40%

0.60%

0.80%

1.00%

1.20%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

Practice

% w

ith D

emen

tia D

iagn

osis

'




%

Note:%



%

Tables%12%and%12%and%Figures%13%and%13%demonstrate%how%both%numbers%of%referrals%and%the%rate%of%referral%

per%1,000%registered%people%have%changed%since%2005.%

'

Key'Observations'

• Both%numbers%and%rates%of%referral%rose%steadily%up%to%2009N10%when%there%was%a%marked%drop%off%

in%both%

• This%was%followed%by%a%steep% increase% in%numbers%and%rates%up%to%2012N2013%where%this% increase%

tailed%off%but%numbers%and%rates%continued%to%rise%%

• There%was%a%sharp%upturn%in%2010%which%may%reflect%changes%to%data%recording%processes%relating%to%

the%introduction%of%the%SystmOne%patient%database%in%primary%care%

%

Table'12''''''Referrals'to'Memory'Assessment'and'Treatment'Services,'BCCCG'2005A2013'

Referrals to MATS

2005-2006 3

2006-2007 6

2007-2008 8

2008-2009 30

2009-2010 35

2010-2011 24

2011-2011 83

2012-2013 95

Grand Total 284%

%

%

%

%

30

Figure'12'''''Numbers'of'Referrals'to'Memory'Assessment'and'Treatment'Services,'BDCCG'2013'

0

10

20

30

40

50

60

70

80

90

100

2005-2006 2006-2007 2007-2008 2008-2009 2009-2010 2010-2011 2011-2011 2012-2013

Year

Number

%%

%

Table'13'''''''Rates'of'Referrals'to'Memory'Assessment'and'Treatment'Services,'BCCCG'2013'


2005-2006 0.0

2006-2007 0.1

2007-2008 0.1

2008-2009 0.3

2009-2010 0.3

2010-2011 0.2

2011-2012 0.8

2012-2013 0.9%

%

%

%

%

%

%

%

%

31

Figure'13'''''''''Rates'of'Referrals'to'Memory'Assessment'and'Treatment'Services,'BCCCG'2013'

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

2005-2006

2006-2007

2007-2008

2008-2009

2009-2010

2010-2011

2011-2012

2012-2013

Year

Rate

per

1,0

00

32

Discussion'

Primary% care% is% the% key% interface% for% clinicians% and% patients% in% respect% of% diagnosis% of%

dementia% and% referral% to% specialist% services,% it% is% the% most% common% place% where% initial%

contact% and% discussions% take% place.% It% is% crucial% that% GPs% and% other% practice% staff% are%

appropriately%equipped%to%mange%this%process%safely%and%effectively%

%The% data% presented% here% provide% an% overview% of% the% primary% dementia% processes% across%

Bradford%and%Airedale.%It% is% important%to%recognise%that%many%patients%live%outside%the%CCG%

area%when%planning%services%

The% prevalence% of% diagnosed% cases% vary% across% CCGs,% likely% due% to% demographic% and%

epidemiological% differences% –% we% will% shortly% add% further% analysis% of% this% based% on% ageN

standardised%analyses%

There% is% evidence% of% statistically% significant% variation% in% diagnosed% prevalence% rates%within%

CCGs% themselves,% further%analysis%of% this%may%provide%valuable% information% regarding% local%

diagnosis%and%referral%cultures%and%processes.%

Section%2%sets%out%the%rising%numbers%of%older%people%in%the%district,%there%is%some%suggestion%

here%that%rates%of%diagnoses%may%be%tailing%off,%as%referred%to%elsewhere%in%this%report,%and%

there%is%evidence%of%this%elsewhere%in%the%developed%world.%This%may%be%evidence%of%a%“mop%

up”%effect%as%outlined%above,%and%it%is%important%that%we%continue%to%monitor%trends.%

'

Recommendations'

• Dementia%must%remain%high%on%the%list%of%strategic%priorities%for%all%CCGs%

• Clinical%audit%of%practice%prevalence%within%CCGs%may%provide%valuable%information%

• CCGs%should%plan%robustly% for%coming%rises% in%demand%for%diagnosis%and%treatment%

services%

• CCGs%should%support%and%develop%work%the%continuing%work%on%Memory%Assessment%

and%Treatment%Services%

'

REFERENCES'

1. Rait%G,%Walters%K,%Griffin%M,%Buszewicz%M,%Petersen% I,%Nazareth% I.%Recent% trends% in%

the% incidence% of% recorded% depression% in% primary% care.% The% British% Journal% of%

Psychiatry.%2009%Nov%30;195(6):520–4.%

2. Downs%M.%Primary%Care%and%Dementia.%The%Journal%of%Quality%Research%in%Dementia.%

Issue%3.%September%2006%

3. http://www.england.nhs.uk/2013/11/29/mapNofNdementiaNservices% % N% accessed%

2/6/2014'

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