NHS Gloucestershire ICB is introducing two new ways of giving earlier support to people with frailty and dementia across all 16 Primary Care Networks. Both follow national guidance that calls for more help in the community, sooner. They aim to help people stay independent for longer, with earlier support to prevent health crises and emergency hospital visits.
The dementia co‑diagnosis model enables faster diagnosis through joint working between GP teams and specialist services, including Gloucestershire Health and Care NHS Foundation Trust’s (GHC) Managing Memory Together Service and the Alzheimer’s Society. It complements the existing consultant‑led Memory Assessment Service.
Four PCNs have implemented the co-diagnosis model so far, with others appointing dementia GP leads and working with GHC to support rollout.
Both models follow five steps: identifying people who may benefit; taking time to understand what matters to the person and the support they need; personalised care and support planning; coordinated multi‑professional working; and ongoing follow‑up.
NHS Gloucestershire ICB has also been chosen as one of seven areas to lead national work to improve care for people living with frailty. The national Frailty Improvement Collaborative aims to ensure people receive earlier support closer to home, reduce avoidable hospital visits and improve experiences across health and care services.